2. I authorize the City of Blaine to initiate entries to debit my bank account for the payment of City utilities at:
   (Fill in your address)
4. Financial Institution's Name
6. The authority is to remain in full force and effect until the City has received written notification from me of its termination in such time and manner as to afford the City a reasonable opportunity to act on it.
8. Phone Number
10. Utility Account Number
12. Date
14. Full Name
16. Signature
18. Submission Instruction
    Attach a voided check and mail form to: City of Blaine, 10801 Town Square Drive NE, Blaine, MN 55449
19. Notice
    Automatic withdrawal will take up to one month to take effect. You will see BANK PAYMENT in the upper right corner of your statement once it has been applied to your account. We will draft your account on the last business day of the month in which your statement was sent.
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20. Print Only

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