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2. You may submit this form via the website, but as THIS IS NOT A SECURE FORM, please do not include your routing or account numbers here. A voided check should be mailed or emailed separately to the Utility Billing Department or placed in our drop box at City Hall.
4. Utility Account Number*
6. First Name*
7. Last Name*
9. Utility Service Address*
11. City*
12. State*
13. Zip Code*
15. Financial Institution Name*
16. Type of Account*

    1. Checking
    2. Savings
18. Phone Number*
19. Email Address
21. Electronic Signature Agreement*

    Yes, I want my utility bill automatically deducted from my bank account each month. Please send my City of North Canton utility bill on the last working day closest to the 15th of each month to my financial institution. I understand that my financial institution will forward my payments to the City of North Canton. I also understand I must follow the rules set by my financial institution. 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.

    1. I agree.
23. Electronic Signature
25. Please remember to mail, email separately, or drop off a voided check, or your application cannot be processed. Continue to pay your bill as normal until you see "Automatic Payment in Effect" on your bill. Thank you.
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field