Direct Payment Authorization Form

I, ________________________________________________, hereby authorize the City of Badger and the financial institution named below to initiate entries to my checking/savings account.

This authority will remain in effect until I notify you in writing to cancel it in such time as to afford the financial institution a reasonable opportunity to act on it. I can stop payment of

any entry by notifying my financial institution three (3) days before my account is charged. I can have the amount of an erroneous charge immediately credited to my account up to fifteen (15)

 days following issuance of my statement or sixty (60) days after posting, whichever occurs first.

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NAME OF FINANCIAL INSTITUTION

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ADDRESS OF FINANCIAL INSTITUTION STREET CITY STATE ZIP CODE

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SIGNATURE DATE

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NAME – PLEASE PRINT

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ADDRESS – PLEASE PRINT

__________________________________________________ OR ____________________________________________________

CHEKCING ACCOUNT NUMBER SAVINGS ACCOUNT NUMBER

FINANCIAL INSTITUTION ROUTING NUMBER ___________________________________________________________________