Equal Pay Plan Application

The Equal Pay Plan for utility services allows residents to pay equal monthly payments year-round. As a participant of the Equal Pay Plan, I agree to and understand all of the following:

Your account must be current.
You must have lived at your current address for at least 12 months.
You authorize Santa Clara City to debit your checking account for the monthly Equal Pay amount for utility services.
The Equal Pay Plan will be reviewed on your anniversary date and be adjusted accordingly.
Two refused electronic fund transfers will cancel this agreement.
You must promptly notify the City of any changes with your bank information. If a change occurs, it is your responsibility to provide the City with current account information.

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Name on the Account:

First

Last

Account Number:

Service Address:

Address Line 1

Address Line 2

City

State

Zip Code

I hereby authorize Santa Clara City to initiate a debit/credit to the financial institution indicated below for the purpose of paying my monthly Equal Pay amount. The financial institution is authorized to debit/credit my account. This is to remain in force and effect until either I revoke it by giving 15 days prior written notice to the City, it is cancelled by the City under the conditions stated above, or upon termination of my service with the City. I have also read and agree to the terms outlined. The equal pay amount will be deducted on the 20th of each month unless specified otherwise.

Financial Institution:

Routing Number:

Bank Account Number:

the Service Bank

Customer Signature

Clear Signature