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BANK / CREDIT CARD DRAFT AUTHORIZATION FORM

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  2. CITY OF LIBERTY HILL

  3. UTILITY BILLING DEPARTMENT
    926 Loop 332
    Post Office Box 1920
    Liberty Hill, Texas 78642
    512-778-5449

  4. BANK / CREDIT CARD DRAFT AUTHORIZATION FORM

  5. Complete the following for Monthly Bank Draft

  6. For Checking Account, attach voided check.
    For Savings Account, attach withdrawal slip.

  7. Complete the following for Monthly Credit Card Draft

    (Please attach a copy of credit card, front and back.)

  8. Please complete Information Below in addition to Uploading Copy of Credit Card

  9. Please agree to the following:*

  10. 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.

  11. Leave This Blank:

  12. This field is not part of the form submission.