2. Your Water Department Account Number*
   Example: R49-00000-00
4. First Name*
5. Last Name*
7. Service Address*
8. Suite or Apartment Number
10. City*
11. State*
12. Zip Code*
14. Mailing Address
    (if different from street address)
16. Primary Phone*
17. Secondary Phone
19. Primary Phone Type*

    1. Home
    2. Work
    3. Mobile
20. Secondary Phone Type

    1. Home
    2. Work
    3. Mobile
22. Email Address*
23. Fax Number
25. Financial Institution*
26. Phone
28. Account Type*

    1. Checking
    2. Savings
29. Account Number*
30. Repeat Account Number*
32. Is this a Credit Union?*

    1. Yes
    2. No
33. Routing Number*
35. Copy of Voided Check*
    Forms that are not complete or do not include a voided check will not be processed or returned.
37. Provisions and Service Agreement for the Department of Water Works Auto-Pay Bill Payment Service
    Note: Payment will be withdrawn on the due date.
39. Payment Notice and Billing Questions
    Your bill will continue to be mailed to you with adequate time to plan for your automatic payment or contact us if you have a question about your bill.
41. Stop Payments
    You may stop any automatic payment by notifying your financial institution at least three business days prior to the payment date. However, when you stop payment on a check, you are responsible for any charges from your financial institution. Please also advise us of any requests to stop payment.
43. Record of Payment
    The amount and date of your automatic payment will be shown on your regular bank statement. This is your proof of payment. If there is a question about payment, or if the amount differs from your bill, you must notify us and your financial institution within 60 days of the date of the statement on which the error is first reflected to initiate an investigation.
45. Availability of Funds
    You are responsible for having enough money in your account on the payment date. You will be charged a fee if your payment is returned for insufficient funds. Your electronic bill payment service will be cancelled if two payments are returned in a 12-month period.
47. Payment Date
    We will notify you prior to your first Auto-Payment. Appropriate funds will be transferred from your checking or savings account as you have designated on your application.
49. Termination
    This authorization will remain in effect until we receive written notice from you 30 days prior to the cancellation date or until your service has been terminated.
51. Account/Address Change
    Please notify us of any account or address changes to ensure timely payments. You are responsible for submitting a new application when an account or address change occurs.
53. All Rights Reserved
    The Michigan City Department of Water Works reserves the right to discontinue any program offer at any time without any prior notice. Forms that are not complete will not be processed or returned. Forms that are not complete or do not include a voided check will not be processed or returned.
55. Authorization*

    I authorized the Department of Water Works of the City of Michigan City and the financial institution listed below to transfer (debit) money from the indicated checking or savings account for payment of my Water and Sanitation bill. I will continue to pay my bill by check until I am notified Auto-Pay service has started. I have read and understood the Auto-Pay service agreement.

    1. I agree
57. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
59. Electronic Signature
Leave This Blank:


61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit Submit and Print

* indicates a required field