Water Bill Automatic Debit Payment Request Form

The Village of Kirkland reserves the right to terminate this payment plan or your participation with written notification.

You are responsible for paying your utility bill to the Village of Kirkland until your bill indicates that your direct debit payment program is established. Your bill will note when the direct debit begins. You further understand that you will continue to receive a bill for your records.

By submitting the request you authorize the Village of Kirkland and the financial institution listed above to debit your account on the scheduled due date of the bill to pay for your utility bill. Each payment will be the same as if it were personally signed and authorized by me.

Click the link below to sign up today.

    Date:

    Your Full Name (required)

    Your Service Address (required)

    Your Billing Address (required)

    Your Email (required)

    Your Phone Number (required)

    Your Service Utility Account Number (required)

    Your Name on Bank Account (required)

    Your Bank Name (required)

    Bank Routing Number (required)

    Bank Account Number (required)

    Bank Account Type: Checking or Savings

    Subject (required)

    Your Message