SUGAR GROVE UTILITY BILL DIRECT PAYMENT
AUTHORIZATION FORM
1. Complete the information requested
2. Write “VOID” across one of your checks and attach it to this form
3. Return this form and your voided check to:
The Village of Sugar Grove
10 S. Municipal Drive
Sugar Grove, IL 60554
Customer Name
Utility Bill Account Number
Service Address
Mailing Address (if different than service address)
Daytime Phone Number
E-Mail Address
Financial Institution Name
Checking Account Number
Routing Number
Routing Number Account Number Check Number
I authorize The Village of Sugar Grove to deduct automatically the amount of my monthly utility bill
from the bank account listed on my check. I understand my automatic payments will be deducted
from my account on the due date of each bill
. In addition, I shall immediately notify the Village
when closing my bank account. I understand that all fees associated with non-sufficient funds or
closed accounts shall apply. This authorization is to remain in effect until the Village of Sugar Grove
receives notice of termination from me. The Village reserves the right to cancel this agreement with
due notification to the water customer.
Authorized Signature Date
New Direct Debit Customer Bank Change notification – (existing direct debit customer)
