ADP Automatic Draft Payment Request Form

Please complete this portion and mail to: Village of Grand Rapids, PO Box 309, Grand Rapids, OH 43522

Name:_________________________________________________ Account Number: _____________________________

Service Address: _____________________________________ City: ______________________ State: _______ Zip: ________

I, _____________________________________ (checking account holder), authorize my bank to make monthly utility bill payments directly to the Village of Grand Rapids and post them to my account.

Bank Name: ______________________________________________   New Banking Info   Revised Info

Authorized Bank Account Number: ________________________________

(attach a VOIDED check showing your name and checking account number)

I understand that I control my payment, and if at any time I decide to discontinue the ADP payment service, I will notify the Village of Grand Rapids. I also understand that if funds are not available in my authorized bank account to pay the utility bill two times in a 12 month period, the Village of Grand Rapids may discontinue my participation in the ADP program. Returned payments due to insufficient funds are subject to established charges.

Signature of authorized bank account holder: ___________________________________________ Date: ________________

Address of authorized bank account holder: ___________________________________________________________________