Enrollment and Authorization

Please check to confirm*

I authorize the City of Coral Springs, Florida to deduct funds from my checking or savings account at the financial institution named below to pay the amounts due on my water utility bill on a monthly basis.I acknowledge that the receipt of a monthly utility bill from the City of Coral Springs constitutes notice to me about the amount that is owed and that amount will be deducted on the payment due date specified on the bill.I understand that once a bill is processed that I cannot stop the automatic payment for that particular month but if any adjustments are needed that they will be on the next bill.In addition, I understand that I can stop these automatic payments if I notify the City’s Water Billing Division at water@coralsprings.gov in writing no less than 20 business days before the due date. I also understand that the city can stop my participation at anytime without notice.I agree to notify the City’s Water Billing Division promptly if I change banks or if my banking account number changes. I understand that there will be a charge to me for each payment that cannot be processed due to insufficient funds, closed account, etc.I also understand that if this automatic debit is not honored by my bank or financial institution for any reason, my utility account will be assessed a late penalty (the amount will be dependent on the amount of the check) and my utility service may be disconnected for nonpayment.Please note that the financial institution may also charge for payments returned from the bank for insufficient funds.

Please select the one that applies*

New AccountStop AccountChange Account

Account Number*

Applicant Name*

First NameLast Name

Daytime Phone Number*

Add your best contact to reach you.

E-mail Address*

example@example.com

Is the service address the same as the billing address?*

YesNo

Service Address*

Street Address

Street Address Line 2

CityState

Zip Code

Billing Address*

Street Address

Street Address Line 2

CityState

Zip Code

Bank / Financial Institution*

Is the account Checking or Savings?*

Checking AccountSavings Account

Checking / Savings #*

ABA/Routing #*

Attach a copy of a voided check for the checking account or a deposit slip for savings account*

Max file size: 25 MB, Accepted file types: .pdf, .jpg, .png

By signing below, I. {applicantName}, hereby authorize the City of Coral Springs to initiate debits electronically, by paper means or by any other commercially accepted method, to my checking account, {checking70} . I authorize my financial institution, {bank}, to debit the same amount.

I also, by signing below, acknowledge that I am the person who has contracted with the city for water service at the location, {serviceAddress}.

By typing my name in the below space, I am electronically signing this form. My signing this electronic signature certifies the information to be true, accurate, and complete.*

First NameLast Name

Date Submitted

MonthDayYear

Hour MinutesAM/PM Option

Enrollment and Authorization

Applicant's Information

Financial Information

Applicant Agreement