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2. Village of Swansea
   1444 Boul Avenue Swansea Illinois 62226 (618) 234-0044
4. Customer Name
5. Sewer Account Number
7. Sewer Address Location Address
9. Daytime Phone Number
10. Financial Institution
12. Bank Account Number
13. Bank Routing Number
15. Please Select Account Type

    1. Checking
    2. Savings
17. I hereby authorize the Village of Swansea to instruct the financial institution indicated below to make my Village of Swansea sewer bill payments from the account listed as they become due.I acknowledge that the organization of ACH transactions to my account must comply with the provisions of U.S. law. I understand that I am in full control of my ELECTRONIC SEWER payments. I may discontinue enrollment at any time with written notice 30 days in advance to the Village of Swansea. Both the Village of Swansea and the financial institution listed reserve the right to terminate this payment plan and/or my ACH participation.
19. Signature
21. Date
23. Please complete this form and enclose it with a voided check or photocopy, and return it to the Village of Swansea.
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