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Authorization Agreement for Recurring Credit Card

  1. National Payment Solutions

    506 Manchester Expressway, Suite A-12
    Columbus, GA 31904

  2. Please input all fields that are not required by hand after printing.

  3. Card Type

  4. Last 3 digits on back of card

  5. Authorization*

    I hereby authorize City of Groveland hereinafter called COMPANY, to initiate a charge to my credit/debit card indicated below for my utility bill. Dishonored payments or charge backs and corresponding service fees will be submitted directly in the office by cash or money order form only as permitted by state law.

  6. Agreement*

    This agreement is to remain in effect until City of Groveland have received written notification of termination 30 days prior in advance.

  7. Important Notice*

    Transfer will occur on the 1st of each month, or the next business day if the 1st falls on a holiday or weekend.

  8. Instructions to Submit the Form

    Print the completed form and return to:
    City of Groveland
    156 S. Lake Avenue
    Groveland, FL 34736
    352-429-2141 option 1

  9. For Personnel Use Only

  10. Leave This Blank: