WATER BILLING AUTO PAYMENTViIIage of Oak Brook
APPLICATION FOR
WATER BILLEヽ G AUTOmTIc Rぼ ⅥMENT
Water Account Number
Last Name, First Name
Street Address City,State,ZIP
Home Telephone No.Work Telephone No.
Name of Financial Institution
Account Type (check one):
Bank Account No.Bank Routing No.
Checking
-
must attacha voided check or photo copy of a check
Savings
-
must attach a deposit slip
-Yes,
I would like my water bill Emailed toz
E解 〃∠磁 !鶴
AUTHORIZATION FOR AUTOMATIC PAYMENT (Please read and sign.)
I authorize the Village of Oak Brook (VOB) and the named financial institution to pay the water bill on the
scheduled due date of the bill. Each payment will be as if it were personally signed and authorized by me. As
with a check, suffrcient funds need to be available in my account at time of ffansfer. If a direct debit automatic
payment is retumed to the Village unpaid, a $25 adminisuation fee and any applicable penalties will be charged
to my water account. This authorization is to remain in effect until the VOB has received written notffication
fromme of termination at least 10 days prior to a scheduled due date. The VOB reserves the right to terminate
this payment plan or my participation at any time with written notification.
I will provide a minimum of 7 days wriffen notice to the VOB of any changes regarding the account, i.e., change
of financial institution, account number, etc. Processing of this application will occur in the next billing cycle
(usually 4 to 6 weeks). I arn responsible for paying my water bill to the YOB until my bill indicates that my
direct debit program is established. My bill will note when direct debit begins. I will continue to be mailed a
bill for my records. I agree to release the VOB from any and all claims and damages resulting from or in
connection with my participation in the Automatic Bill Payment Plan.
I understand and agree to the terms of this letter and application.
Signature
Please mail completed
application and necessary
documentation to:
VⅢage of Oak Brook
Atm: Water Department
1200 0ak Brook Road
Oak Brook,IL 60523-2255
Ⅱollrs: 8:00 am to 4:30 pm
Pholle: (630)368-5080
Fax: (630)368-5081
Email: heuis@oak‐br00k.org