VILLAGE OF SLINGER UTILITIES
300 Slinger Road
Slinger, WI 53086
262-644-5265
Fax: 262-644-6341

AUTOMATIC PAYMENT AUTHORIZATION

Your Village of Slinger Utilities are very pleased to offer you the convenience of automatic payment of your utilities account. Simply complete the authorization form below and return it to our office at the above address. Your utilities payment will be automatically deducted from the checking or savings account you indicate on the 5^th of each month.

You will continue to receive your utilities statement each month on or about the 20^th, which will give you adequate time to ensure the necessary funds are available. Instead of showing an amount due, your statement will show you the amount that will be deducted from your account on the 5^th of the next month.

I authorize the Village of Slinger and Slinger Utilities through my designated bank to automatically withdraw and transfer to the Village’s bank account the monthly amount due on my Slinger Utilities account(s). Funds will be withdrawn on the 5^th of each month and I will receive notification of the amount to be withdrawn in a monthly statement. I understand that if there are insufficient funds in my account at the time the automatic deduction is to be transacted, an additional non-sufficient funds fee will be assessed to my utilities account. I also understand that this authorization remains in effect until such time that I notify the Village of Slinger in writing that I wish to terminate the automatic payment.

NAME: ______________________________________ Phone #:__________________

Service Address: _________________________________________________________

Utilities Account #:____________________________

Financial Institution Name:_______________________________

Account Number at Financial Institution:____________________ Checking (  )

                                                                                                                  Savings   (  )

Financial Institution ABA Routing Number:________________________________

Financial Institution City and State:_______________________________________

Signature                                                                         Date