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City of Pilot Point Automatic Bank Draft Payment Authorization Form PCI

  1. I (we) hereby authorize the City of Pilot Point to initiate debit entries to my account indicated below.

  2. I authorize the City of Pilot Point Water Utility Department to:

  3. I agree to the following:

  4. 1. I will provide the City of Pilot Point with a voided check or a bank document (a deposit slip will not be an accepted document) with my name and account information. Documents may be submitted by faxing to 940-686-4338, or drop off at City Hall, 102 E. Main St. Pilot Point, TX 76258.

  5. 2. I will be responsible for all fees resulting from uncollected payments due to non-sufficient funds, closed bank account, incorrect account number, etc.

  6. 3. I attest I am an authorized owner of the account listed below.

  7. 4. This authority is to remain in full force until I submit in writing that I wish to terminate.

  8. As it appears on billing statement.

  9. As it appears on billing statement

  10. Please make a copy of a voided check, or ACH form from your Financial Institution/Bank and fax to (940) 686-4338 attention Utility Billing.

  11. Leave This Blank:

  12. This field is not part of the form submission.