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2. Date:*
   Date:
4. Select to either authorize or terminate automatic payment:*
   -- Select One --AuthorizeTerminate
6. I Authorize the City of Rosenberg to discontinue/initiate debit entries my checking or savings account indicating from the depository below:*
   -- Select One --CheckingSavings

8. Note: Please attach a voided check to this sheet. The payment will be drafted on the bill due date. If there are any questions call (832)595-3400.

10. Upload Voided Check*

12. Financial Branch Information

14. Financial Branch Name:*
16. Transit/ABA Number - Bank Routing Number:*
18. Bank Account Number:*

20. Note: Please note termination of automated bank draft form must be submitted seven (7) business days prior to the utility bill due date to prevent from drafting your bank account. If there are any questions, call (832)595-3400.

22. Utility Account Information
24. Account Number:*
26. Account Name:*
28. Service Address:*
30. Cell/Work Number:*
32. Home Number:
34. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
36. Electronic Signature
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field