CITY OF RICE
	205 MAIN STREET E
	P.O. BOX 179
	RICE, MN 56367 

	DIRECT PAYMENT APPLICATION
I authorize the CITY OF RICE to initiate electronic debit entries to my ____ Checking Account (or) _____ Savings Account for 
payment of my utility bill.
I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.  This 
authority will remain in effect until I have cancelled it in writing.
Customer __________________________________	 Service Address __________________________________ 
Account ___________________________________	 Phone __________________________________________
Email_____________________________________

Signature _______________________________________ Date _______________________________________
Financial Institution (Please Print) _________________________________________________________
Financial Institution Routing Number _______________________________________________________
Financial Institution Account Number _______________________________________________________
Financial Institution City and State _________________________________________________________
	
Payment will be withdrawn on the 20th of each month.
Must give 30-day notice to stop or change automatic withdrawal. 
Insufficient Funds Charge $35.00