Automatic Debits (ACH Debits)

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Please return completed form with a void check to:

Attn: ACH Debit
City of Cocoa
65 Stone St.
Cocoa, Florida 32922
Fax 321-433-8408

Company Name: The City of Cocoa
Company Tax ID#: 59-6000292

I hereby authorize the City of Cocoa to initiate debit entries and to initiate, if necessary, credit enties or adjustments for any entries in error to my bank account and the financial institution named below

Discontinuation of this service must be submitted in writing
Please Check One
This authority is to remain in full force and effect until the City of Cocoa has received written notification from me, of its termination in a timely manner, as to afford the City of Cocoa and the financial institution named above a reasonable opportunity to act on it.
Customer Information
The first bill after the ACH debit has been set up will be prenoted (Tested). If the prenote is sucessful, your ACH debit will be in effect on the second bill. The message: "Your bank account will be drafted", on your water bill, will indicate activation. The bank anticipate the actual withdrawal from your account will be approximately 7 days from the BILL DATE.
This form must be signed and a void check must be attached. Deposit slips cannot be accepted.
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