Form Center

2. Authorization Agreement for Automatic (ACH) Debits
   I (we) hereby authorize the Village of Riverside, hereinafter called COMPANY, to initiate debit entries and if necessary, credit entries and adjustments for any debit entries in error to my/our account indicated below, for payment of Water and Sewer Bill and the depository named below, hereinafter called DEPOSITORY, to debit and/or credit the same to such account.
4. Depository (Bank) Name
5. Branch
7. City
8. State
9. Zip Code
11. Transit/ABA Number
12. Account Number
14. Account Type

    1. Checking
    2. Savings
16. This authority is to remain in full force and effect until the COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.
18. Utility Account Number
20. Name
21. Phone Number
23. Address
25. Signature
26. Date
    Date
28. IMPORTANT
    This form MUST be returned to the Village Hall, 27 Riverside Road, Riverside, IL 60546 with an ORIGINAL signature (not electronic signature) and VOIDED check (if debiting a checking account). Please note that it takes one billing cycle for your auto-debit to become effective. You will know when this debit has become active as it will say "Auto Pay" in the amount due box near the bottom of the water bill.
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