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2. Automatic Payment Plan Request*

   1. Add (New Authorization)
   2. Change (Changes to Financial Institution and/or Account #)
   3. Delete/Remove (Cancel future Autopay withdrawals)
4. First Name*
5. Last Name*
7. Address2*
9. City
10. State
11. Zip
13. Telephone Number*
15. Utility Bill Account Number*
17. Upload a copy of your check or a letter from your financial institute.*
19. Agreement

    By submitting this form, I authorize the Village of Germantown to instruct my financial institution to deduct my Utility Bill payment due from my account. Approximate withdrawal dates are: April 20th, July 20th, October 20th, and January 20th. If at any time I decide to change my financial institution and/or account number, move from this location, or wish to discontinue this payment service, I will notify the Village of Germantown, in writing, 30 days prior to cancellation. 

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21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit

* indicates a required field