Pre-authorized Payment Form

By submitting this form, you are authorizing the Town of Carleton Place to debit your account for the payment of taxes and/or water billings as chosen for the option indicated.

First Name*

Last Name*

Address*

Email Address

Phone*

Roll Number:*

Bank:

Branch Address*

Bank Account Number:*

Options for Taxes - Please note these options require that there be no outstanding arrears on the account to enroll and continue in the program. Any additional charges for hydro liens and legal fees for example must be paid forthwith to maintain the privilege of preauthorized payment. This authorization may be cancelled at any time upon written notice.*

Options 1 - Funds to be removed from individual account on normal tax due date four times in the year on March 1st - June 1st - September 1st and November 1st

Option 2 - Funds to be removed from individual's account on the 10th of the month from February to November - first five installments being equal to 50% of the prior year's taxes and the remaining five installments being equal to the final levey less instalments paid to date

Option 3 - funds to be removed from individual's account on the normal water due dates four times in the year on February 1st - May 1st - August 1st and November 1st

Please attach a personal cheque marked VOID (a void cheque is not required if you are already enrolled in the program on the installment payment method and are just switching to Option 2)

Enter the code displayed*