Fillable Pre-Authorized Debit Plan Application Form printable pdf download

Pre-Authorized Debit Plan Application Form

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Pre-Authorized Debit Plan Application Form

Part 1 – Customer Information

Applicant Name:

Property Address:

Anmore, B.C. Postal Code:

Daytime Phone:

Email: ___________________________________________________

Part 2 – Bank Account Information

Note: A void personalized cheque must be attached to this form for new applications and change of banking information

Select ONE of the following:

for new applicant(s) or change of banking information

VOID personalized cheque is attached –

for existing participants only

Use existing Banking Information on file –

Monthly Pre-Payment to Property Tax Roll #

in the amount: $

Monthly Pre-Payment to Utility Account #

in the amount: $

Effective Date:

, 20

**CURRENT AND PRIOR YEAR PROPERTY TAXES/UTILITIES MUST BE PAID IN FULL PRIOR TO ENROLLING**

 New

 Change Amount

 Change Bank Account

 Cancel

Part 3 – Pre-Authorized Debit Details

I/We hereby authorize the Village of Anmore to debit my/our bank account, as per the attached VOID cheque,

on the 15

of each month, from August to May of each year and do not require advance notice of any withdrawal

before it is processed. I/We have read, understand and agree to the Terms and Conditions (see reverse) and

understand that prepayments WILL NOT be refunded. Withdrawals will continue until 10 days written

notification of cancellation has been received. I/we will instruct the Village to discontinue the plan if the

property is sold.

I/we understand that it is my/our responsibility to ensure that the conveyancing lawyer or

notary provides me/us with a credit on the Statement of Adjustments, where applicable

For a joint bank account, all depositors must sign if more than one signature is required on cheques issued against the account.

Signature(s) of Bank Account Holder(s)

Signature of Registered Owner (if different)

Print Name(s)

Print Name

Date:

Please see reverse for Terms and Conditions

For Office Use Only

Date Entered:

Initials:

TX:

UB:

PAD Acct#:

Pre-Authorized Debit Plan Application Form

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