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2. Completing this form authorizes the City of Le Mars to initiate debit/credit adjustments to your bank account for water, sewer, and garbage fees. Before completing this form, be sure to have a saved scan of your check. It will be required to complete this form.
4. Prefix (Mr., Mrs., Ms., etc.)
6. First Name*
7. Last Name*
9. Suffix (Sr., Jr., etc.)
11. Utility Address*
13. City*
14. State*
15. Zip*
17. Country*
18. Phone Number*
20. Utility Account Number
    See water bill for account number.
24. Bank Name*
26. Bank Address*
28. Address Line 2
30. City*
31. State*
32. Zip*
34. Country*
35. Bank Branch Phone Number*
37. Bank Routing Number*
38. Bank Account Number*
40. Account Type*

    1. Checking
    2. Savings
41. Check Scan
    Upload an electronic scan of your check
45. Terms and Conditions
    I hereby authorize the City of Le Mars to initiate debit/credit entries and adjustments to my bank account as shown above for water, sewer, and garbage fees until revoked by me in writing to City of Le Mars, Le Mars, Iowa, 51031. I understand that I must contact City of Le Mars concerning bill discrepancies prior to the scheduled draft date (25th of each month). City of Le Mars will have 30 days to change my billing.
    
    I understand City of Le Mars reserves the right to terminate my participation in the auto-pay plan. I understand that City of Le Mars may impose a nominal processing fee if a bill is not paid by my financial institution.
47. Accepting the Terms and Conditions*

    1. I accept
    2. I decline
48. Your Email Address*
Leave This Blank:


50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit

* indicates a required field