Public Art Fund Donation

Name*

Address*

City*

State*

ZIP*

Account No.* - -

######## - ### - #

Phone No.* - -

(###) - ### - ####

Monthly

$10 $20 $50 $100 $

I hereby authorize the City of Edmond to add my pre-selected amount per month to my city utility bill in support of the Visual Arts Program. The donation will be used to fund the activities of the Visual Arts Commission. I understand that all past due amounts on my account must be paid in full before any donation to the arts will be accepted. I understand that in order to stop the automatic donation I must contact the Utility Office at 359-4541 and verbally cancel the donation.

Refunds on donations cannot be given. The City of Edmond Utility Office will not distribute 1099s on the donated amount.

I am authorized to make contractual obligations on behalf of this account.

Type I AGREE in the box below if you agree with the terms stated above.

Authorization*