What does the ACH Debit Authorization Agreement do?

It authorizes the City of Jefferson Public Works to debit a customer's bank account for utility bills. Debits are scheduled for the 10th of each month, or the next business day if that date falls on a weekend or holiday.

What should I attach to the ACH agreement?

The form requests a voided check. It also asks for your utility account number, depository and account information, start date, name, phone number, signature, and date.

Do I need a notary for the ACH Debit Authorization Agreement?

No. This document is signed without a notary. Attach a voided check, and sign and date the agreement.

Jefferson, GA · Jackson County

No notary required

Authorization Agreement for ACH Debit

Jefferson utility customers use this agreement to authorize recurring ACH debits from a bank account for their utility bill.

What this form is

This agreement authorizes the City of Jefferson Public Works to debit a customer's bank account for utility bills. It asks for the utility account number, depository and bank account details, a start date, and the customer's contact information and signature. The agreement says debits occur on the 10th of each month, or the next business day when the 10th falls on a weekend or holiday, and requests a voided check.

Who needs it

Jefferson utility customers who want their bills paid by recurring ACH debit complete this agreement and attach a voided check.

How to submit it

Submit it to the city department named on the form; check the city website for current contact details.

About notarization

This document is signed without a notary; attach a voided check, and the signer just signs and dates the agreement.

How to submit this form

1
Download The Agreement
Download the Authorization Agreement for ACH Debit.
2
Complete The Form
Enter your utility account number, bank details, start date, name, phone number, signature, and date.
3
Attach A Voided Check
Include the voided check requested on the form.
4
Submit To The City
Submit it to the city department named on the form; check the city website for current contact details.

Frequently asked questions

What does the ACH Debit Authorization Agreement do?: It authorizes the City of Jefferson Public Works to debit a customer's bank account for utility bills. Debits are scheduled for the 10th of each month, or the next business day if that date falls on a weekend or holiday.
What should I attach to the ACH agreement?: The form requests a voided check. It also asks for your utility account number, depository and account information, start date, name, phone number, signature, and date.
Do I need a notary for the ACH Debit Authorization Agreement?: No. This document is signed without a notary. Attach a voided check, and sign and date the agreement.
How do I submit the ACH Debit Authorization Agreement?: Submit it to the city department named on the form; check the city website for current contact details.

Need something notarized?

This Authorization Agreement for ACH Debit doesn’t need a notary — but if you have another Jefferson form that does, a commissioned online notary can help.