BOROUGH OF WANAQUE
Enrollment and Authorization Form to Pay your Tax / Utility Bill

I authorize the Wanaque Borough to deduct funds from my checking or savings account at the financial institution named below to pay the amounts due on my Tax/Water/Sewer bill on a quarterly basis. I understand that once a bill is processed that I cannot stop the automatic payment for that particular month but if any adjustments are needed that they will be on the next bill. In addition, I understand that I can stop these automatic payments if I notify the Tax/Utility office in person no less than 20 business days before the due date. I also understand that the Borough can stop my participation at anytime without notice. I agree to notify the  Tax/Utility Billing Dept. promptly if I change banks or if my banking account number changes. I understand that there will be a charge to me for each payment that cannot be processed due to insufficient funds, closed account, etc. I also understand that if this automatic debit is not honored by my bank or financial institution for any reason, my account will be assessed a late penalty (the amount will be dependent on the amount of the check) and my utility service may be disconnected for nonpayment. Please note that the Financial Institution may also charge for payments returned from the bank for insufficient funds.

PRINT Name :_______________________________________________________

Address: ________________________________________________________

Your Mailing Address (if different from location address): ______________________________________________________

TAX                 BLOCK____________ LOT ________  QUALIFIER  ____________

WATER           ACCOUNT NUMBER _____________________    

SEWER           ACCOUNT NUMBER _____________________

Daytime Phone Number: _____________________Email Address: _______________________
 
Bank or Financial Institution:______________________________________________________

* Checking or    * Savings      Account Number:______________________________________

Your ABA/Routing Number:_______________________________________________________

Check One:

* ADD - Withdraw Funds directly from my account*

or I am currently participating in the Direct Withdrawal Program:

* CHANGE - Change my financial institution &/or account number*

* CANCEL - Stop my participation in this program
 

Signature ____________________________

Date _______________________________

** Please attach a voided check or a deposit slip for each account listed.
 We will be unable to process your application without this information.