Utility Billing Refund Electronic Transfer (EFT) Form

Utility Billing Refund Electronic Transfer (EFT) Form
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Previous Service Address *
Financial Institution Name *
ABA Routing *
Account Number *
Voided Check or direct deposit form*

Cancelof
I authorize the City of Melissa to deposit any utility billing refund via EFT to the account indicated above.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: