Please complete and sign form, attach a voided check, print and mail to the Village of Cary, 655 Village Hall Drive, Cary, IL 60013.

I (we) authorize the Village of Cary and the financial institution listed below to transfer (debit) money from my (our) checking or savings account and remit payment for my (our) water & sewer bill.

Financial Institution Name*

Financial Institution Address*

City*

State*

Zip*

Bank Account Number*

Bank Routing Number*

This authorization will remain in effect until the Village of Cary has received written notification from the account holder of its termination.

Signature for Authorization*

Date*

Signature for Authorization

Date

Property Address*

Village of Cary Water & Sewer Account Number*

Daytime phone number*