ACH direct debit (for water, sewer, and/or taxes) application

Complete the application below and select the Submit button. The information you provide will be automatically sent to the village. A village representative will then contact you.

For complete details about this form click here.

YES! I would like to participate in the Village of Bloomfield's free Direct Debit Payment Program and make my water and sewer payments and/or taxes automatically.

I authorize the Village of Bloomfield to initiate entries to my checking/savings account for my water and sewer payment each quarter to pay my bill automatically. This authority will reamain in effect until I notify you in writing to cancel it in such time as to afford the Village of Bloomfield reasonable opportunity to act on it. I can stop payment of any entry by notifying my financial instutition 3 days before my account is charged.

NOTE: After submitting this application you must bring a voided check for a checking account or a savings deposit ticket for a savings account to the Village office for this application to be fully processed.

The account to be debited is a (select one):

Checking Account

Savings Account

Please debit my account the 15th of the month for: *

water/sewer payments

June village taxes

Name of Applicant *

Phone Number *

Email Address *

Street Address *

Water/Sewer Bill Account Number *

Draw your signature in the space below using a mouse, stylus, or your finger.

Check this box to attest that this application is your own and the information it contains is as accurate as possible.