_____________________________________________________________________________
Auto Pay
By Credit/Debit Card

The City of Peoria now offers another payment option for its utility customers. You can now pay your bill 
automatically each month with either your debit or credit card. Just complete the authorization at the bottom of this 
form and return it to our office. Upon receipt, you will be automatically enrolled, so please specify when you would 
like to start your Automatic Payments. Our Customer Service Staff will gladly send out a confirmation notice 
including the date of the first payment to be deducted. You will continue to receive your monthly statements, which 
will advise how much will be charged to your credit or debit card. All payments will be deducted on the due date 
listed on your monthly statements. 


Customer Name ________________________________________________________________________________

Utility Account No _____________________________________________________________________________

Service Address ________________________________________________________________________________

Mailing Address _______________________________________________________________________________
				(if different from Service Address)

Daytime Phone ( ___ ) ___________________                  Alternate Phone ( ___ ) ______________________

PLEASE CHOOSE ONE PAYMENT METHOD
AND PROVIDE ALL REQUIRED INFORMATION

	   DEBIT CARD –  Automatic                             	      CREDIT CARD –Automatic
	   Payments through checking account.                               Payments through credit account. 

Account # on card*  __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ Expiration Date  __ __ / __ __
        (*American Express account numbers consist of only 15 digits, all others will have 16)

 Card Type:                 American Express              Discover Card               Master Card              Visa


You are hereby authorized and requested, until otherwise instructed, to charge to the above referenced account all 
utility charges rendered against the undersigned by the City of Peoria for the service address listed above.  Utility 
charges may include one or more of the following services: water, sewer, or sanitation. 

I understand requests to discontinue or change this service must be made in writing and be forwarded to the City of 
Peoria, Customer Service Division, 8401 W. Monroe St, Peoria, AZ 85345, by mail or fax. 
Phone: (623)773-7160   Fax: (623)773-7159.

If a transaction is DECLINED, a courtesy phone call will be attempted once at the daytime number listed above by a 
Customer Service Representative. If you are unable to reach me at that number, please call the alternate number listed 
above. I am aware that if my payment is made after the due date a penalty will be applied and will not be waived due 
to a DECLINED transaction. In the event I am unable to be reached, I understand I am still accountable for my utility 
payments to be made in a timely manner. 
					

____________________________    _____________________________    __________
	(Name as printed on card)			(Signature as on card)		        (Date)