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Application for Automatic Bank Withdrawal 




Attach a Void Cheque or Authorized Bank Account Information

By checking "I agree," I hereby authorize the City of Medicine Hat and its Financial Institution to debit the bank account provided for the balance of the Utility account each month. I also acknowledge that the payment will be forwarded to the bank at least 3 business days prior to the actual withdrawal date. I am also aware that bills with a total credit amount will result in no transaction activity on my bank account for that month.

If a payment is returned for any reason, I will be removed from the Automatic Bank Withdrawal Program. A deposit may be required.


Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

By submitting this application/form you acknowledge and agree that any electronic signature provided by you herein is the same as a handwritten signature for the purposes of legality, validity, enforceability, and admissibility.

Do you agree to the above terms and conditions?