Direct Pay Program Application & Agreement
Please Enclose a Voided Check or Check Copy

__________________________________________ Port Hueneme, CA 93041  
SERVICE ADDRESS

__________________________________________      ___________________
NAME                                                                               PHONE NUMBER

__________________________________________      ___________________
NAME OF YOUR FINANCIAL INSTITUTION             ACCOUNT NUMBER

I hereby authorize the City of Port Hueneme and my financial institution designated above to automatically deduct from the above mentioned account all future payments for my utility bill.  I understand that both the City of Port Hueneme and my financial institution reserve the right to terminate the authorization and my participation therein.  If I chose to terminate this authorization, I will immediately notify the City of Port Hueneme.

____________________________________________________         _________________
SIGNATURE                                                                                                            DATE

 

To Mail your Direct-Pay application:

       Step 1:   Complete form above
       Step 2:   Include a voided check, or check copy OR attach your check for your
                      next regular payment
       Step 3:   Send to: City of Port Hueneme
                                  Finance Department
                                  250 North Ventura Road
                                  Port Hueneme, CA  93041

To Deliver your Direct-Pay application in person:

       Step 1:   Complete form above
       Step 2:   Include a voided check, or check copy OR attach your check for your
                      next regular payment
       Step 3:   Bring to address stated above