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2. CUSTOMER INFORMATION
4. First Name*
5. Last Name*
7. Account Number*
9. Service Address*
11. City*
12. State*
13. Zip Code*
15. Phone Number*
16. Email Address*
20. FINANCIAL INSTITUTION
22. Bank Name*
24. Bank Address
26. City
27. State
28. Zip Code
30. Phone*
34. ACCOUNT INFORMATION
36. Name on Account*
38. Routing Number*
39. Account Number*
43. CONTRACT
    By submitting this request I am instructing my banking institution to make payments from the account listed above to the City of Seaside for payment of the Water Utility bill associated with the address listed. If at any time I wish to discontinue this payment service, I will notify the City of Seaside at 831-899-6715.
45. Electronic Signature Agreement

    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.
47. Electronic Signature*
48. Date*
    Date
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50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit

* indicates a required field