Authorization Agreement for Auto-Draft Payments/E-Billing

*Effective March 1, 2018, all credit card drafts will be subject to a 2.50% surcharge per transaction. There will continue to be no fee associated with bank drafts.

In order to process your application, we ask you to provide the following information. Please note that all fields marked with an asterisk (*) are required.

Personal Info
Service Address
Payment method
Bank Draft
Credit Card Draft
Billing Address
Files must be less than 10 MB.
Allowed file types: gif jpg jpeg png txt pdf doc docx.

This authorization will remain in effect until I notify the Town of Harrisburg that I no longer desire this service, allowing reasonable time to act upon my notification. I have the right to stop payment of a debit entry by notifying my financial institution. This action must be taken, at least, 3 business days prior to the scheduled debit.

I understand that if corrections of the debit amount are necessary, it may involve an adjustment (debit or credit) to my account. If an erroneous debit entry is charged to my account, I have the right to have the amount of the entry credited to my account by my financial institution. Corrections must be made within 60-days following the statement of account.

Note: There is no charge for bank drafts. There is a 2.50% surcharge applied to each credit card draft transaction. Applications received by the end of the month will be set for draft on the 10th of the immediately following month. All new bank draft applicants will have the noted account prenoted prior to the actual draft occurring. This may show up as a $0.00 draft on your bank statement. This is the method the Town uses to verify correct account information before the first draft occurs.

This authorization is non-negotiable and non-transferable


Please initial to agree that you verify that the above information is correct and accurate to the best of your knowledge and that you also understand and agree with the content/stipulations listed above.