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Direct Debit Payment Program AUTHORIZATION AGREEMENT - DIRECT DEBIT PAYMENT PROGRAM Water/Sewer Bills I hereby authorize the Village of Burr Ridge and the Financial Institution designated herein to begin deductions for Direct Debit in payment of utility bill. I understand my automatic withdrawal of the billing amount will be made every two months on the bill’s due date, as indicated on the statement received from the Village. I hereby agree to have such funds available on said due date as specified in this Agreement. If funds are not available in my account on the payment date, the pre-authorized debit will be returned by my Financial Institution. I understand that if this occurs it will be handled as if I had a check returned for non-sufficient funds. I will be assessed 10% penalty on the amount due and incur the relating $25.00 Returned Check Fee, as well as any charges issued by my Financial Institution. This authority will remain in effect until Village of Burr Ridge has received written notification of termination at least 30 days prior to termination. Please Type or Print All Information Financial Institution: _____________________________________________________ Address: _______________________________________________________________ City: _______________________________ State: _______ Zip Code: ___________ Bank Account Number: _________________ Bank Routing Number: ______________
Name: ________________________________________________________________ Service Address: ___________________________ Phone Number: ______________ Billing Address: _________________________________________________________ Village of Burr Ridge Account Number: ________________________Date: _________ Authorized Signature: ____________________________________________________ Please remember to attach a voided check to Authorization Form.
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