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2. 
3. Town of Bel Air Auto Pay (Bank Draft) Authorization Form
   Upon receipt of this form, we will process a test file to withdraw $.00 from your bank account by the 15th of the month. If that transaction is not successful, we will notify you. If it is successful, you will receive an e-mail notification. Your Auto Pay will go into effect on the 24th of the month. Each month thereafter, we will send you a statement showing the amount of your Utility Bill which is the amount that will be deducted from your bank account on the 24th of each month. For more information, please e-mail utility@belairmd.org. Call 410-638-4555 with questions.
7. Please select all that apply from the following: *

   Please select all that apply from the following:

   1. Enrollment
   2. Change my current information
   3. Stop my Auto pay , effective immediately
   4. I want to receive my bills via email (shown below)
8. Utility Acct# *
   Do not include dashes.
10. Name*
    First
11. Name*
    Last
13. Phone Number*
14. Email*
16. Address1*
18. Address2
20. City*
21. State*
22. Zip*
24. Bank Name*
25. Bank Account #*
27. Bank Account Routing#*
28. Account Type*

    1. Checking
    2. Savings

    Checking or Savings
30. I authorize the Town of Bel Air to withdraw payments against my bank account for my Utility bills until this authorization is revoked in writing and received by the Town of Bel Air at least 10 business days prior to presentation of a draft; or until the Town of Bel Air revokes this service due to insufficient funds or other non-payments. The bank is authorized to pay these drafts when so drawn and presented for payment and to charge the same to my account. I further agree to notify the Town of Bel Air if I withdraw this authorization.
32. eSignature*
33. Date*
    Date
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field