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ACH Authorization Request Form

The city is now offering payments via ACH. This will simplify our payment process and provide you with faster payments. Should you wish to participate, please complete the form below.

I hereby authorize the City of Mesquite NV to initiate ACH payments into the account listed below, and, if necessary, initiate adjustments for any transactions credited/debited in error. *

Individual / Company Name

Name of Financial Institution

Financial Institution Mailing Address

City

State Value is not selected

Zip

Type of Account

Checking

Savings

ABA Routing Number

Re-enter ABA Routing Number

Account Number

Re-enter Account Number

Email for Payment Notification

Comments

This authorization will remain in effect until the City of Mesquite NV is notified by me in writing to cancel it in such a time as to afford the City of Mesquite NV and the Financial Institution a reasonable opportunity to act on it. *

Full Name

Date

Signature

Upload Additional Documents Example: W-9

This form can be submitted here or by fax or mail

Fax:

(702) 346-2908
Attn: Accounts Payable

Mail:

City of Mesquite
Attn: Accounts Payable
10 E Mesquite Blvd
Mesquite NV 89027

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ACH Authorization Request Form