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Authorization Agreement for Automated Payments

Please use the following form to submit the Authorization Agreement For Automated Payments. If you would like to mail the form or deliver in-person to City Hall, please download the form here.

 


I (we) hereby authorize the City of Bunker Hill Village to initiate debit entries to my (our) checking or savings account indicated below and the DEPOSITORY named below to debit same to such account for the purpose of paying my utility bill.

This authority is to remain in full force and effect until the City of Bunker Hill Village and DEPOSITORY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford the City of Bunker Hill Village and Depository a reasonable opportunity to act upon it.

Name (As shown on the utility bill)(*)
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Email Address(*)
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Phone Number(*)
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Service Address(*)
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Account Number on Utility Bill:(*)
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Depository Name/Bank: (*)
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Routing Number(*)
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Bank Account Number(*)
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I am aware that the amount drafted will be debited from my account according to the following schedule unless the 18th falls on Saturday, Sunday or a holiday, in which case the debit will be made the following business day.

January 18th, March 18th, May 18th, July 18th, September 18th and November 18th.

I (we) are aware that we will still receive a bill. I (we) will not receive any further statements or bills when the amount is drafted from our account. Once automatic draft is set up, DRAFT PAYMENT will be written on the utility bill.

Signature(s)(*)
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Code(*)
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