Do I need a notary for the ACH direct debit form?

No. Sign and date the form without a notary, and attach a voided check to verify the routing and account numbers.

How do I submit the ACH direct debit form?

Return the completed form and a voided check to the City of Bingen at 112 N Ash Street, PO Box 607, Bingen, WA 98605, or email deputyclerk@bingenwashington.org.

What should I attach to the enrollment form?

Attach a voided check to verify the routing and account numbers. The form says not to use numbers from a deposit slip or attach a deposit slip.

When should I return the form to start payments?

Return the completed form by the 10th of a month to begin automatic payments that month.

Bingen, WA · Klickitat County

No notary required

Authorization Agreement for Direct Debit Payments (ACH Debits)

Bingen utility customers use this form to authorize monthly automatic bill payments from a checking or savings account.

What this form is

This form authorizes the City of Bingen to debit a customer’s bank account monthly for utility payments. Customers complete it to enroll in automatic payments and attach a voided check so the city can verify the routing and account numbers. The form asks for customer and utility account details, contact information, bank information, and a signature and date.

Who needs it

Bingen utility customers who want their bills paid automatically from a checking or savings account should complete this enrollment form.

How to submit it

Return the completed form with a voided check to the City of Bingen, 112 N Ash Street, PO Box 607, Bingen, Washington 98605, or email [email protected]. Return it by the 10th of a month to begin automatic payments that month.

About notarization

This form is signed and dated without a notary; attach a voided check for account verification, and no sworn or notarized step is stated.

How to submit this form

1
Download The Form
Download the City of Bingen ACH direct debit authorization form.
2
Complete The Form
Fill in your name, utility account number, contact details, bank information, and sign and date the authorization.
3
Attach A Voided Check
Include a voided check to verify your routing and account numbers; do not attach a deposit slip.
4
Return The Form
Return the form and check to the City of Bingen by the 10th of a month to begin payments that month.

Frequently asked questions

Do I need a notary for the ACH direct debit form?: No. Sign and date the form without a notary, and attach a voided check to verify the routing and account numbers.
How do I submit the ACH direct debit form?: Return the completed form and a voided check to the City of Bingen at 112 N Ash Street, PO Box 607, Bingen, WA 98605, or email [email protected].
What should I attach to the enrollment form?: Attach a voided check to verify the routing and account numbers. The form says not to use numbers from a deposit slip or attach a deposit slip.
When should I return the form to start payments?: Return the completed form by the 10th of a month to begin automatic payments that month.

Need something notarized?

This Authorization Agreement for Direct Debit Payments (ACH Debits) doesn’t need a notary — but if you have another Bingen form that does, a commissioned online notary can help.