Authority For Automatic Payments

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Authority for automatic payments
TIP: If you need help filling out this
form, a help guide is on the back.
(Not to operate as an assignment or an agreement)
To the Manager
Westpac
Your branch
NAME
Please tick one, and complete ALL sections
new automatic payment, OR
change an existing automatic payment. The current amount being paid is $
A: Pay from
Pay from
NAME
Pay from
BANK
BRANCH
ACCOUNT
SUFFIX
Details to appear on my/our bank statement:
PARTICULARS
CODE
REFERENCE
B: Payment details
Regular payment amount
$
First variable payment amount if different from regular amount
$
(if required)
OR
Last variable payment amount if different from regular amount
$
(if required)
Frequency (please tick one)
Weekly
Fortnightly
Monthly
4-weekly
6-monthly
Quarterly
Yearly
First payment date
/
/
DAY
MONTH
YEAR
Last payment date
/
/
DAY
MONTH
YEAR
OR
Until further notice (please tick)
C: Pay to
Pay to
NAME
Pay to
BANK
BRANCH
ACCOUNT
SUFFIX
Details to appear on their bank statement:
PARTICULARS
CODE
REFERENCE
D: Authorisation
1. Please make this automatic payment as detailed by debiting my/our account.
2. I/we understand and accept that the Bank accepts this authority only on the conditions overleaf.
Customer’ s signature
Contact phone number
Date
/
/
DAY
MONTH
YEAR
Customer’ s Name ________________________________________________________________________________________
Customer’ s signature
Contact phone number
Date
/
/
DAY
MONTH
YEAR
Customer’ s Name ________________________________________________________________________________________
Westpac use only
Date received
/
/
Received by
DAY
MONTH
YEAR
please turn over

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