I (we) authorize the City of Waukegan to terminate any transfers (debit) money from my (our) checking or savings account for payment to the City of Waukegan for my (our) water account and to bill me (us) directly for payment.

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Date of Termination

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Signature for Authorization                                                                          Date

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

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Billing Address

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Water Account Number(s)

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