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Village of Hanover Park Direct Debit Authorization Form

  1. Customer Information

  2. Financial Institution Information

  3. Account Type*
  4. 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.

  5. 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.

  6. Leave This Blank:

  7. This field is not part of the form submission.