Authorization to Pay Bill by ACH Bank Draft

City of Mountain Home Water and Wastewater Department
752 North College Street
Mountain Home, AR 72653
870-425-5115
[email protected]

[{"type":"text","required":true,"label":"Name on Account","description":"Name as it appears on water bill","name":"Name-on-Account","className":"d-block","subtype":"text"},{"type":"text","required":true,"label":"Service Address","name":"Service-Address","className":"d-block","subtype":"text"},{"type":"text","subtype":"tel","required":true,"label":"Phone Number ","name":"Phone-Number","className":"d-block"},{"type":"text","required":true,"label":"Water Service Account Number","name":"Account-Number-","className":"d-block","subtype":"text"},{"type":"radio-group","required":true,"label":"Bank Account Type","inline":true,"name":"Bank-Account-","className":"d-block","values":[{"label":"Checking","value":"Checking"},{"label":"Savings","value":"Savings"}]},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"Please attach a voided check or other official bank document showing the routing and account numbers. Failure to provide the required documentation will result in this submission being considered incomplete and void.","className":"d-block"},{"type":"file","required":true,"label":"You may upload up to 20 files (35 Mb max). Files can be PDF, JPG, JPEG format. To upload multiple files, please hold control while clicking on multiple files before clicking \"Open\".","name":"Bank-Document-","subtype":"file","multiple":true,"className":"d-block"},{"type":"checkbox-group","required":true,"label":"I hereby authorize Mountain Home Public Works to electronically debit my bank account on the 10th of the month or next business day for the amount due on my Mountain Home Water and Wastewater bill and to make such deductions payable to the order of Mountain Home Public Works.","name":"Confirmation","className":"d-block","values":[{"label":"I understand","value":"I understand"}]},{"type":"text","required":true,"label":"Signature","placeholder":"Type your full name","name":"Signature","className":"col-md-6","subtype":"text"},{"type":"date","label":"Date Signed","name":"Date-Signed","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"PLEASE NOTE: Autopay online is an automatic payment with a debit or credit card (processing fee applies) and is different than ACH bank draft. Signing up for autopay online will cancel your authorization to bank draft. If you want your account to be bank drafted, do not sign up for autopay online.","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"}]