Village of Oreana Water/Sewer Direct Debit Form

Village of Oreana Water/Sewer Direct Debit Form
Name*

First NameLast Name
Oreana Water/Sewer Account # (if not known, leave blank)
9 Digit Bank Routing Number*
Bank Account Number*
Service Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
I hereby authorize the Village of Oreana and the financial institution designated herein, to initiate automatic deductions by direct debit to my bank account indicated below, as payment for my utility bill. I understand the automatic withdrawal of the amount billed will be debited (withdrawn) on the due date printed on the bill. If the due date falls on a weekend or holiday, my account will be debited on the following business day. This authorization request overrides any and all previously submitted requests. I hereby agree to have such funds available on said due date as specified in this agreement. This authority will remain in effect until the Village of Oreana has received written notification at least ten (10) days prior to the next billing date. If the information provided is false or inaccurate, the Village will deny the application and reserves the right to pursue any and all civil and criminal remedies provided by law. With my signature, I certify that all the information provided on this form is true, accurate and complete.
Signature*

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