2. Customer Information

4. Name*
5. Service Address*
7. Phone Number
8. Village of Hanover Park Utility Bill Account Number*
10. Email*

14. Financial Institution Information

16. Name*
17. Address*
19. City*
20. State*
22. Zip Code*
23. Phone Number*
25. Bank Account Number*
26. Routing Number*
28. Account Type*

    1. Checking - attach a blank voided check
    2. Savings - attach a blank voided deposit ticket
29. Check/Deposit slip Upload*

31. I authorize the Village of Hanover Park to initiate debit entries to my account indicated above. I understand automatic payment of the total amount due will be made on the bill’s due date. This authority is to remain in full force and effect until I revoke the agreement by written notification to the Village in such time and manner to afford a reasonable opportunity to act upon the notice. I have the right to stop payment of a charge by notifying the Village three business days prior to the due date on my bill. I understand that both the Village and the financial institution named above reserve the right to terminate this agreement or my participation, therein. A copy of this authorization will be provided at your request. I have read and agree to the terms of this direct debit payment plan.

33. Today's Date*
    Today's Date
34. Name*

    DISCLAIMER: By typing your name here, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field