CITY OF MONTICELLO

AUTHORIZATION FOR DIRECT PAYMENT OF UTILITY BILL

I authorize the City of Monticello and the financial institution listed below to initiate electronic debit entries, and if necessary, credit entries and adjustments for any entries in error to me on the 5^th of each month.  This authority will remain in effect until I have cancelled it in writing.

_____  Checking Account     _____  Savings Account

___________________________________                        ___________________________________

Financial Institution                                                                Name

___________________________________                        ___________________________________

Branch                                                                                    Account Number

___________________________________                        ___________________________________

City/State                                                                                Signature/Date

Financial Institution Routing Number:  _________________________

STAPLE VOIDED CHECK HERE

Provide this form along with a voided check to:

City Hall

245 South Mulberry Street

P.O. Box 553

Monticello, FL  32345