1

Name

 *

Name

2

Service Address

 *

Service Address

3

Mailing Address (if different from above)

Mailing Address (if different from above)

4

Daytime Phone Number

 *

Daytime Phone Number ext.

5

Email Address

Email Address

6

Paperless Billing?

Paperless Billing?

Yes

No

7

Property occupied by:

Property occupied by:

Owner

Tenant or non-owner

8

Bank Routing Number

Bank Routing Number

9

Bank Account Number

Bank Account Number

I hereby authorize the Village of Elk Grove to instruct my financial institution to initiate payment for my utility bill for the account listed above on its respective due date. This authority will remain in effect until revoked by me via written notification to the Village of Elk Grove. I understand it will take the Village approximately five business days upon receipt to set-up the auto draft program with my banking institution. 

10

Electronic Signature:

Electronic Signature:

If you should have any questions or concerns, please contact Utility Billing at 847-357-4060.

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

Page 1 / 1