Water Pre-authorized Payment Form

Name(Required)

First Last

Address(Required)

Street Address City Province Postal Code

Email(Required)

Phone(Required)

Roll Number(Required)

Bank

Branch Address(Required)

Street Address City

Bank Account Number(Required)

Options for Payments(Required)

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

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

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 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.

VOID Cheque

Max. file size: 64 MB.

Please attach a personal cheque marked VOID.