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Direct Payment Authorization Form

  1. I authorize the Town of Lyons to initiate electronic debit entries to my:

    For payment of my Town of Lyons Utility Bill on or about the 20th of each month.

  2. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. The authority will remain in effect until I have cancelled it in writing.

  3. Signature:*

    By checking the box below I agree that the information provided on the form is accurate.

  4. Leave This Blank: