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Electronic Billing Application

2. Instructions
   Electronic billing makes it more convenient for you to receive your bi-monthly Water and Sewer bill from the Village of Round Lake Beach. E-billing allows the Village and its residents to reduce paper usage, which is friendly to the environment and helps to conserve our nation’s forests. Unlike regular mail, which can be lost or stolen, e-bills are delivered directly to your specified email address. Once you have received your bill, if you have questions about specific charges, simply contact the Village at 847-546-2351. There is no charge for this service. To enroll, just complete the application and click SUBMIT. Or complete the PDF application and return or mail it to: Village of Round Lake Beach C/O Electronic Water Billing 1937 N. Municipal Way Round Lake Beach, IL 60073 Submit Via email: waterbills@rlbeach.org Please note, you will no longer continue to receive a paper copy of your Water and Sewer bill once you have opted for e-billing. The Village must be notified of any email address changes as soon as possible to avoid a late bill. To terminate e-billing, simply notify the Village in writing that you wish to discontinue the electronic billing service. If you have any other questions, please contact the Village at 847-546-2351.
4. Customer Name (As it appears on Bill)*
   Please type customer name as it appears on Water Bill; please note that this name must match the name on the water bill.
6. Property Owner (if different than Customer Name)
   Please type the property owner name here if it is not the same as the Customer Name
8. Village Account Number*
   This is a 12-digit account number which appears on your bill. The format is as follows ##########-##
9. Account PIN#*
   The account pin is a 7-character alpha-numeric code printed on your bill. This is used to protect your account information.
11. Service Address*
13. Billing Address (Full)
    Please enter your billing address if different than service address (enter full address: street, city, state, zip code)
15. Email Address*
    Please enter your email address here; this is the email where your bill will be sent. Note below is a link to a document showing a sample water bill.
16. Daytime Phone Number*
    Please enter your telephone number on this field. This will be the number used to contact you in case of any questions.
18. Sample Water & Sewer Electronic Bill Document
    Sample Electronic Bill

    Please click here to see a sample PDF of an electronic water and sewer bill statement.
19. Submit Form via Email or Print PDF
    Open PDF Version of Form

    Please click here to open a PDF version of this form, fill it out on the computer or by hand\scan, and email it (waterbills@rlbeach.org) or mail it (1937 N. Municipal Way, Round Lake Beach, IL 60073).
21. CERTIFICATION & AUTHORIZATION
    I hereby authorize the Village of Round Lake Beach to initiate electronic water/sewer bill(s) via e-mail for the account(s) listed above. I acknowledge that it is my responsibility to notify the Village of any changes in the e-mail address. Failure to receive a statement or update an e-mail address does not relieve me of the responsibility of making payments as they are due. I understand that by approving this service I will no longer receive a mailed paper statement. Entering my name below will serve as my “electronic signature”.
23. Signature:
24. Date:
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit | Go Back