EZ-Pay Form Edit Form EZ- Pay Form for Water & Sewer Payments How does it work? Your bi-monthly payment is automatically taken from the account you authorize the bank to use, and the money is directly credited to your water and sewer account at the Village of Buffalo Grove. You'll continue to receive a statement for your records, but you won't have to respond. EZ-Pay will do it for you. The Village of Buffalo Grove is authorized only to receive the amount of money specified by the usage of water and sewer on your bi-monthly billing statement notification. The EZ-Pay system takes care of everything else. If you don't like the service, you can cancel it with only 30 days notice to the Village of Buffalo Grove. Customer Name* Account Number* Billable Address* Mailing Address* Daytime Phone Number* Email Address* Financial Institution* Institution Address* Checking Account Number* Upload Image of Voided Check* Agreement and Disclosure StatementPayment Notice and Billing Questions Upon approval of this EZ-Pay application, you will have approximately ten days to plan for your automatic payment or contact us with questions. Stop Payments Stop payments can be issued up to three days prior to your payment date. As with checks, you are responsible for any charges associated with the stop payment. You may be required to provide written confirmation of the stop payment to your financial institution. Please contact the Village of Buffalo Grove if you have requested a stop payment. Record of Payment Your monthly bank statement will indicate the amount and date of your automatic transfer. Retain this record as proof of payment for future reference regarding your billing. If a question arises regarding your transfer or if the amount differs from your bill, you must notify us and your financial institution within sixty days of the date of the questioned statement. Your financial institution will advise you of rights concerning an error. Availability of Funds You are responsible for having enough money in the account you designated on your payment date. You are responsible for any fees associated with non-sufficient funds. EZ-Pay may be cancelled if two payments are returned within a 12 month period. Payment Date You will be notified prior to your first payment. The predetermined amount will be transferred from your checking account on the date your payment is due. If your payment date falls on a weekend or holiday, you account will be debited on the following business day. Termination Your service will remain in effect unless we receive written notice from you 30 days prior to the cancellation date or until your service is terminated. Account/Address Change Notify the Village of Buffalo Grove of any account or address changes as soon as possible for uninterrupted billing. I agree to the above disclosure statement* Yes No