Alameda Power and Telecom (A Department of the City of Alameda)    Automatic Payment Service

To participate in the Automatic Payment Service, please complete this form. Print it out, and mail it with a check marked VOID and which shows your complete account number to:

AUTOMATIC PAYMENT SERVICE
Alameda Power & Telecom
Customer Service Department
P.O. Box H
Alameda, CA 94501

Name as shown on your electric bill:
Service Address:
Work Telephone:
Home Telephone:
Alameda P&T Acct Number: -
Banking Information
Name of your Bank, Savings and Loan, or Credit Union:
Branch Location:
Type of Account from which You Wish Funds Transferred: Checking Account
Savings Account
Credit Union
Bank Account Number:
Your Name (please print) as shown on financial institution records:
Signature as shown on financial institution records:
Date:
Bank Authorization

I authorize Alameda Power & Telecom to begin deductions from my account with the financial institution named below for payment of my electric bill. This authorization will remain in effect until revoked by me in writing. I understand that I have the right to stop automatic payment of my electric bill upon 30 days written notice to Alameda Power & Telecom and/or my designated financial institution prior to the time my account is charged. I understand that Alameda Power & Telecom and/or the financial institution indicated reserve the right to end this payment plan and my participation therein.

I authorize ___________________________________________ (Name of Financial Institution) to pay and charge my account the amount of any Automatic Payment Service drawn on my account payable to Alameda Power & Telecom.

 
Your Signature: _________________________________________
Date: _________________________________________