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2. Direct Debit: A Fast, Safe & Easy Way to Pay Your Palos Park Utility Bill
   Direct Debit allows Utility Customers to make payment automatically by electronic transfer from a checking or savings account directly to the Village on the date it is due. Your bank will post the transaction on your monthly statement. To enroll just fill out this form, attach a voided check and return it to the Kaptur Administration Center, 8999 West 123rd Street, Palos Park. Please note that it takes time to process your first electronic transfer. Your Utility Bill will state **Auto Pay Date** under the due date once your account has been activated for Direct Debit.
4. Authorization Form
   I (we) hereby authorize the Village of Palos Park (“the Village”) to make withdrawals and, if necessary, debit correction and adjustment entries to my (our) account at the listed Depository Financial I 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.
6. Financial Institution Name
7. Bank Address
9. Routing & Transit Number
10. Account Number
12. Bank Account Type

    1. Checking
    2. Savings
14. Utility Bill Account Number (As it Appears On Your Statement)
16. (Recipient Signature)
17. (Printed Name)
19. (Recipient Signature)
20. (Printed Name)
22. Address
23. Phone Number
25. Date
    Date
27. Please Attach a Voided Check.
    Return to: Village of Palos Park 8999 W 123 Road Street Palos Park, IL 60464
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