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2. Please Note
   Please allow sufficient time to process your changes. Your account will indicate “Auto Pay” below the due date when your change has taken effect.
4. Authorization Form to Change Information
   I (we) hereby authorize the Village of Palos Park (“the Village”) to make changes to my direct debit information as listed below. I (we) also authorize the Village of Palos Park (“the Village”) to make and, if necessary, debit correction and adjustment entries to my (our) account at the listed Depository Financial Institution and authorize the Depository Financial Institution to charge these withdrawals, debit correction and adjustments from my account listed below for payment of my Utility Account. Withdrawals shall be made corresponding to normal billing dates. It is agreed that these withdrawals and adjustments may be made electronically and under the rules of the National Automated Clearing House Association. This authorization is to remain in full force and effect, until the Village has received written notification of its termination in sufficient time to afford the Village a reasonable opportunity to act upon it. The Village reserves the right to terminate this agreement at any time. In the event that electronic transfer is not possible because of insufficient funds in the account listed below, I understand it will be my responsibility to make up the payment and I will be charged a late payment fee.
8. Date
   Date
9. Phone Number
11. Utility Bill Account Number
    As it appears on your statement.
13. Printed Name
14. Service Address
16. Signature
20. Current Information
22. Financial Institution Name
23. Bank Address
25. Routing & Transit Number
26. Account Number
28. Bank Account Type

    1. Checking
    2. Savings
32. Revised Information
34. Financial Institution Name
35. Bank Address
37. Routing & Transit Number
38. Account Number
40. Bank Account Type

    1. Checking
    2. Savings
42. Please Attach a Voided Check
    Return to: Village of Palos Park 8999 W 123 Road Street Palos Park, IL 60464
Leave This Blank:


43. Print Only

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