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2. Financial Institution Name:*
4. City*
5. State*
7. Bank Account Number*
8. Bank Routing Number:*
10. Attach photo of voided check
    Please take a photo of a voided check for this checking account and upload here.
12. *Checking Accounts Only*
    I (we) authorize the Village of Skokie and the financial institution listed above to transfer (debit) money from my (our) checking account and remit payment to the Village of Skokie for my (our) water bill. I have read the terms of this application and agree to the terms. This authorization will remain in full force and effect until the Village of Skokie has received written notification from me (or either of us) of its termination in such time and in such manner as to allow the Village and my financial institution a reasonable opportunity to act on it. I (we) further understand that it is my (our) sole responsibility to maintain sufficient available funds in my (our) bank account to provide for payment to the Village of Skokie on the payment due date. In the event that there are insufficient funds in the account and my financial institution denies payment to the Village, I understand that the Village will add the amount of any bank charge it incurs as a result of the insufficient funds to my water billing account.
14. Date*
15. Customer Name (as appears on bill) type or print*
16. Signature for Authorization*
18. Address*
19. City*
20. State*
21. Zip Code*
23. Water Account Number*
24. Daytime Telephone Number*
26. To contact the Water Billing Division, please call 847/933-8418.
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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit Submit and Print

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