Provo City

E-Z Pay Form


Provo City Power E-Z Pay Plan Authorization Form


251 W. 800 N. - Provo, UT 84601 - (801) 852-6820


I authorize the Provo City Energy Department and my financial institution to automatically deduct my monthly utility bill from my checking account on the due date listed on my monthly bill. I understand that it is my responsibility to ensure sufficient funds are in my account at that time. If sufficient funds are not available at the time of the draft process, a $25.00 service fee will be assessed. This authorization will remain in effect until I instruct the Provo City Energy Department to cancel or change this arrangement by calling Customer Services at (801) 852-6808 at least five (5) business days prior to the due date of the next automatic payment. The Provo City Energy Department retains the right to remove a customer from the E-Z Pay Plan for just cause at any time.

Customer Name:

_______________________________

Day phone:

_______________________________

Utility Acct. #

_______________________________

Service Address:

_______________________________
_______________________________
_______________________________

Financial Institution
and Address:

_______________________________
_______________________________
_______________________________
_______________________________

Checking Acct. #

_______________________________

IMPORTANT: Please enclose a blank check marked "VOID" with this authorization form to ensure accurate processing and enclose it with your next utility bill payment. Automatic deductions will go into effect as soon as we complete processing your authorization form and will apply to the statements you receive which indicate that the bill amount will be drafted.

Signature:

_______________________________

Date:

___________________