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Direct Debit Change Authorization Form

  1. Please allow sufficient time to process your changes. Your account will indicate “Auto Pay” below the due date when your change has taken effect.

  2. 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.

  3. As it appears on your statement.

  4. Bank Account Type

  5. Bank Account Type

  6. Return to:
    Village of Palos Park
    8999 W 123 Road Street
    Palos Park, IL 60464

  7. Leave This Blank: