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2. Account Number*
   (as it appears on your bill)
4. Name*
   (as it appears on your bill)
5. Phone Number*
7. Email*
9. Location Address*
   (as it appears on your bill)
11. Name of Bank*
13. Address of Bank*
14. City/State*
15. Zip Code*
17. Routing Number*
18. Account Number*
20. Type of Account*

    1. Checking

    1. Savings
21. Voided Check*
    Please upload a picture or scan of a VOIDED check
23. Paperless Billing (Optional)

    I hereby authorize the City of Henderson to send my bill through my email address. I understand I will no longer receive a standard paper bill via the US Postal Service until this email option has been voided. Prompt notification of changes of my email address to the City of Henderson will be my responsibility.

    1. I have read the Paperless Billing Authorization and wish to sign up for paperless billing using the email above
25. Auto Pay Authorization*

    I hereby authorize the City of Henderson to make automatic withdrawals from the financial institution and account specified on this authorization form. I understand that the funds will be withdrawn from my account on my normal due date. This authorization will remain in effect until cancelled by the City of Henderson or via signature by me.

    1. I have read and accept the Auto Pay Authorization
27. Signature*
28. Date*
    Date
Leave This Blank:


30. Submit

* indicates a required field