SIGN UP FOR AUTO PAY

Please fill out the Utility Billing Automatic ACH Authorization Form below or you may request a paper copy at the Town Hall office.

ACH Customer Form 2101

CUSTOMER INFORMATION

Please fill out the customer information below. A member of the Town will contact you if any further information is needed.

For any questions or more information, contact the Office of the Clerk-Treasurer of the Town of Shipshewana by Phone: 260-768-4743 or Email: [email protected]

Customer's First Name

Customer's Last Name

Billing Address

City

State

Zip Code

Customer's Telephone Number

Customer's FAX Number

Customer's Email Address

How would you like to receive your utility bills and payment receipts?

Email listed above

Postal mail to the Customer Billing Address on File

Postal mail to a temporary (Seasonal) address

Temporary or Seasonal Address

Address Line 1

City

State

Zip Code

Billing Contact

Other Billing Contact First Name

Other Billing Contact Last Name

Other Billing Contact Telephone Number

Other Billing Contact Email

FINANCIAL INSTITUTION INFORMATION

Please fill out the information below. A member of the Town will contact you if any further information is needed.

Bank Name

Bank Address

Address Line 1

Address Line 2

City

State

Zip Code

Name(s) on Bank Account

FINANCIAL ACCOUNT INFORMATION

Please fill out the information below. A member of the Town will contact you if any further information is needed.

ACH Check Example

Bank Account Type

Checking

Savings

Business Checking

Business Savings

ACH Routing Number (9 Digits)

ACH Bank Account Number

A voided check or bank confirmation letter is required to process this form. You may use the File Upload here to upload one; a copy may also be FAXed to 260-768-4608 or emailed to [email protected].

File Upload: VOID Check

Choose File

CERTIFICATION AND AUTHORIZATION

I certify I am responsible for notifying any changes to the information provided above to the Town of Shipshewana.

I certify that I agree to immediately return any erroneous transactions that may occur as a result of payment via ACH.

I certify the information provided on this form is true and correct, and that I, as an authorized representative for the above-named company or customer, herby authorize the Town of Shipshewana to electronically pull payments from the designated bank account and, if necessary, initiate adjustments for any transactions credited or debited in error. This authorization remains in full force until written notice of change or cancellation is received by the Clerk-Treasurer of the Town of Shipshewana. The Town of Shipshewana reserves the right to cancel or suspend this authorization at any time.

Signature of Authorized Official

Sign Here

Authorized Official's Name

Title (If Applicable)

Date Signed