Automatic Bank Payment Authorization Form

 

 

Name of Financial Institution ___________________________________________________

 

City ________________________________    State ________________________________

 

ABA Bank Routing Number _____________________________________________________

 

Bank Account Number  ________________________________________________________

 

Account Type (Mark one)     ___   Checking          ___   Savings

 

(Attach a voided check for checking account or a deposit slip for savings account)

 

 

I (we) authorize the City of Waukegan and the financial institution listed above to transfer (debit) money from my (our) checking or savings account and remit payment to the City of Waukegan for my (our) water bill.

 

I have read and agree to the terms of this application.  This authorization will remain in full force and effect until the City of Waukegan has received written notification from me (us) of its termination in such time and in such manner as to  allow the City and my (our) financial institution a reasonable opportunity to act on it.

 

I (we) further understand that it is my (our) sole responsibility to maintain sufficient available funds in my (our) account to provide for payment to the City of Waukegan on the due date.  In the event that there are insufficient funds in the account and my financial institution denies payment to the City, I understand that the City will add a $35.00 service fee to my water billing account.

 

 

 

_______________________________________                        _________________________

Signature for Authorization                                                                      Date

 

____________________________________________________________________________

Customer Name as it appears on the bill (please print or type)

 

____________________________________________________________________________

Billing Address

 

_______________      _______________      _______________      _______________

Water Account Number(s)

 

__________________________________     _________________________________

              Day Telephone Number                                              Evening Telephone Number

 

 

 

 

 

 

 

Please return completed form to:  The City of Waukegan, Water Billing Department, 106 North Martin Luther King Jr. Avenue, Waukegan Illinois 60085 or direct any questions to 847-360-0535.