Please complete this form to request electronic funds transfer (EFT) of invoice payments. Completed forms should be submitted to the Village Finance Department - Accounts Payable,
14700 S. Ravinia Avenue, Orland Park, Illinois 60462.
Questions can be directed to our Email or (708) 403-6184.

Company Name*

Contact Name*

Address*

City*

State*

Zip Code*

Phone Number*

Email Address*

Financial Institution Name*

ABA Routing Number*

Bank Account Number*

I hereby authorize the Village of Orland Park to deposit, by electronic funds transfer, payments owed by the Village of Orland Park and, if necessary, complete debit entries and adjustments for any amounts electronically deposited in error. The Village shall deposit said payments in the financial institution and account designated above. This authority is to remain in full force and effect until the VILLAGE OF ORLAND PARK has received written notification of its termination in such time and in such manner as to afford the VILLAGE and DEPOSITORY a reasonable opportunity to act on said notification.

Authorized Signature

Date