Automatic Payment Cancellation Form for Water/Sewer Utility

The Village of Sussex Finance Department must receive written notification up to 10 days before the end of the calendar quarter in order to cancel your participation in the automatic payment program. If proper notice is not received and an automatic payment is returned because of non-sufficient funds or because an account has been closed we will pass along the bank charges of $30 to the utility customer.

Please fill out the information below if:

You are discontinuing your participation in the automatic payment program.
You have changed the bank/account from which funds are being withdrawn.

* Please note: If you are changing bank accounts you will need to fill out a new application for automatic payment with your new account information as well as the cancellation form for the old account.

Should you have any questions, please contact the Finance Department at (262) 246-5224.

Phone Number

Utility Account #

Effective Date

I authorize the Sussex Utilities to cancel my participation in the utility billing automatic payment program.

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First Name

Last Name

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

A $30 fee will be charged if you have not cancelled your automatic payment plan and your payment is returned because of non-sufficient funds or your account was closed.