6925 Providence Street . PO Box 2476 . Whitehouse, Ohio 43571
Phone 419-877-5383 . Fax 419-877-5635
whitehouseoh.gov
__________________________________________________________
Automatic Direct Payment – Water / Sewer Bill
I, _____________________________________ (printed name), authorize the Village of
Whitehouse to debit my checking/savings account indicated below, hereinafter called Bank, the
amount due for my monthly water, sanitary sewer, and/or refuse usage.
This authorization is to remain in force until the Village of Whitehouse has received written
notice from me of its cancellation in such time and in such manner as to afford the Village of
Whitehouse and the Bank a reasonable amount of time to act upon such notice.
The Village further reserves the right to terminate the customer’s participation in this plan for
good cause.
Please attach a voided check or a copy of a check to this document. Failure to attach
appropriate verifiable account documentation may lead to returned payment fees.
Service Address: ______________________________________________________________
Phone No. _________________________ Whitehouse Water Account No. _______________
E-mail address: _______________________________________________________________
Signature: ________________________________________________ Date: _____________
Name of Banking Institution
Savings or
Checking Acct.
