STAMP HERE
1 Olde Half Day Road, Lincolnshire, IL 60069
AUTOMATIC UTILITY PAY AGREEMENT
Your water and sewer bill amount will be automatically deducted from your approved bank account and
paid to the Village of Lincolnshire so you’ll never miss a payment. This program will save you time, check
writing and postage costs, and minimize the chance of lost or late payments. Each transaction will appear
on your monthly bank statement and you will continue to receive your regular copy of your water and
sewer bill. You can enroll by taking the following steps:
1. Complete and sign the Authorization Agreement below.
2. Provide a voided check for the bank account to be debited. If using savings, include the deposit slip.
3. Return the signed Agreement and voided check to: Village of Lincolnshire, 1 Olde Half Day Road,
Lincolnshire, IL 60069 or leave in the drop-box outside Village Hall. You can also fax the documents to
847-883-8608, Attn: Finance.
Frequently Asked Questions
Q: What authority does the Village of Lincolnshire have to take a payment from my account?
A: The authorization you provide will be governed by the terms of the Agreement you sign below.
Q: When does money need to be in my bank account to pay my water/sewer bill?
A: Your bank account must hold the full amount of the payment, in available funds, on the billing due
date. If there are insufficient funds in your account on the due date, your bank will reject the pre-
authorized debit and you may be penalized by both the bank and Village, just as if a check was rejected
for non-sufficient funds.
Q: What record will I have of a pre-authorized withdrawal from my bank account?
A: Your monthly bank statement will show all transfers from your bank account. It will state the amount
and when the payment was made to the Village of Lincolnshire.
AUTHORIZATION AGREEMENT FOR AUTOMATIC UTILITY PAY
Select One: Checking / Savings
Select One: New Enrollment / Change
• I hereby authorize the Village of Lincolnshire and the Financial Institution designated to begin
automatic deductions for my water and sewer bills. I understand the automatic withdrawal of the
billing amount will be made on each bill’s due date, typically the 25th of each month.
• Please attach a voided check. Applications are processed on the 18
th
of each month and become
effective immediately. Applications received after the 18
th
will be processed the subsequent month.
• This authority is to remain in effect until the Village of Lincolnshire receives notification from me of
termination or until the Village notifies me of termination of this agreement (in the event of move
outs or closed bank accounts). The Village of Lincolnshire requires 5 days advance notice to terminate
this agreement.
Signature: ____________________________________________________ Date: _______________
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