Enter your Unitil account number (as shown at the top of your bill). Provide the checking account routing and account numbers for the bank or other financial institution account from which you would like your Unitil bills deducted.

Customer name:
Unitil account number:
Street address:
I authorize Unitil to instruct my bank to withdraw the amount of my bill directly from my checking account. I understand that if at anytime I decide to terminate my participation in the plan, I will notify Unitil in writing at 5 McGuire St, Concord, NH 03301, Attn: Customer Service Department. I understand and agree that Unitil is not liable for any damages which may result from a transfer made on a disputed bill if I do not contact Unitil at least 5 days prior to the scheduled transfer date. I understand that my participation in the Uni-Pay plan is subject to Unitil's approval and Unitil reserves the right, upon written notice to me, to terminate the Uni-Pay plan and/or my participation in the plan. Unitil will send me a confirmation letter once I am enrolled in the Uni-Pay plan.
Name on bank account:
Routing Number (9-digit):   Account Number:
Home phone (XXX) XXX-XXXX:
Email address: