Village AutoPay Application

Name:

*required

Service Address:

*required

Billing Address (if different):

Email:

*required

Phone #:

( ) -

*required

Utility Service Account #:

*required* If you do not know, put Unknown.

Name of Bank:

*required

Bank Routing #:

*required

Account #:

*required

Account Type:

*required

	The Village of Hampshire reserves the right to terminate this payment plan or my participation with written notification.

	I am responsible for paying my utility bill to the Village of Hampshire until my bill indicates that my direct debit payment program is established. My bill will note when the direct debit begins. I further understand that I will continue to receive a bill for my records.

	I hereby authorize the Village of Hampshire and the financial institution listed above to debit my account on the scheduled due date of the bill to pay for my utility bill. Each payment will be the same as if it were personally signed and authorized by me.

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