Please complete this form to enroll in the Village's automatic water bill payment program.

Signed, completed forms, with a voided check attached, should be submitted to:
Village of Orland Park Water Billing Department
14700 S. Ravinia Avenue
Orland Park, Illinois 60462

Account Number:*

Name(s):*

Service Address:*

Social Security Number:

Driver's License Number:

Daytime Phone Number:*

ATTACH VOIDED CHECK HERE.

I hereby authorize the Village of Orland Park to electronically transfer funds from my bank account to my water bill account for the total bi-monthly amount due. I agree to maintain sufficient cleared funds in my bank account to cover these electronic transfers. In the event that an electronic transfer is not possible because of insufficient funds in my account, I understand that it will be my responsibility to ensure that payment is made and I may be charged a non-sufficient funds (NSF) fee and a late payment fee. I agree to continue to pay my water bills until a BANK DRAFT - DO NOT PAY appears in the amount due box on my water bill. This authority is to remain in full force and effect until the Village of Orland Park has received written notification from me (or either of us) of its termination in such time and such manner as to afford the Village and the depository bank a reasonable opportunity to act on it.

Signature Required:

Date:

Signature:

Date: