Purcellville, VA · Loudoun County
ACH Authorization Agreement
Utility customers use this agreement to authorize the Town of Purcellville to make automatic water and sewer bill payments from a checking or savings account.
What this form is
This agreement lets utility customers authorize automatic withdrawals for water and sewer bills from a checking or savings account. Use it to enroll, change bank information, temporarily cancel, or permanently cancel ACH payments. The form asks for utility account and service address details, bank and account information when applicable, and the account owner's contact information, signature, and date.
Who needs it
Purcellville water and sewer customers who want to enroll in, update, or cancel automatic payments complete the applicable section.
How to submit it
Email the completed form and a voided check or deposit slip to [email protected], or return them to the 24-hour Payment Drop Box on the J Street side of Town Hall. You can also mail them to 221 S Nursery Ave., Purcellville, VA 20132.
About notarization
This agreement is signed and dated without a notary; include a voided check for checking or a voided deposit slip for savings, neither of which the form says must be notarized.
How to submit this form
- 1
Download The Agreement
Download the ACH Authorization Agreement for Purcellville utility bill payments.
- 2
Complete The Applicable Section
Select enrollment, bank information change, temporary cancellation, or permanent cancellation, then fill in the requested details.
- 3
Gather The Bank Document
Include a voided check for a checking account or a voided deposit slip for a savings account.
- 4
Submit The Form
Email the form and bank document to [email protected], use the Town Hall payment drop box, or mail them to the listed address.
Frequently asked questions
- Do I need a notary for the ACH Authorization Agreement?
- No. The agreement calls for the account owner's signature and date, not a notary. Include a voided check for checking or a voided deposit slip for savings.
- How do I submit the ACH Authorization Agreement?
- Email the completed form and required bank document to [email protected], use the 24-hour Payment Drop Box on the J Street side of Town Hall, or mail them to 221 S Nursery Ave., Purcellville, VA 20132.
- What bank information does the form request?
- For enrollment or bank changes, it asks for the bank name, branch, city, state, ZIP code, routing number, account number, and whether the account is checking or savings.
- Can I use the form to cancel ACH payments?
- Yes. It includes options to cancel ACH temporarily or permanently. For temporary cancellation, the form says to fill in the account number, address, date, and signature; bank information is not needed.
Need something notarized?
This ACH Authorization Agreement doesn’t need a notary — but if you have another Purcellville form that does, a commissioned online notary can help.