Direct Debit Form With Service Agreement Template
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1
2Office Use Only
PN:
COFFS HARBOUR CITY COUNCIL
Locked Bag 155, Coffs Harbour NSW 2450
Entered
Advised P / L
Ph (02) 6648 4000 Fax: (02) 6648 4199
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DIRECT DEBIT REQUEST
Your Surname Name (or Company Name)
Request &
Authority to
Debit
Given Name(s) (or ABN / ARBN)
Your Postal Address
Your Day-time Phone No.
I/We request and authorise Coffs Harbour City Council (User ID No. 087029) through
its own financial institution, to debit my / our account any amount Coffs Harbour City
Council has deemed payable.
This debit or charge will be made through the Bulk Electronic Clearing System (BECS)
from your account held at the financial institution you have nominated below and will
be subject to the terms and conditions of the Direct Debit Request Service Agreement.
This request is to remain in force until the Council is notified, in writing, to terminate it.
Your Financial Institution and Branch
Your Bank
Account
Name of Account Holder(s)
Details
BSB Number
Account Number
(These numbers are usually found on your bank statement – they are not the numbers on your plastic card)
Your Council Property No.
(Found on your Rate & Water accounts)
Council
Account
Property Address
Information
RATES
WATER
Tick the box (or boxes) for
which account type you would
NOTE: If you own more than one property for which you would also like to use Direct Debit
like to pay via Direct Debit
for account payment please list these below.
I / We confirm the above request and agree to the Terms & Conditions of the Coffs Harbour City
Your
Council Direct Debit Request Service Agreement.
Confirmation
Signatures of Account Holder(s)
Date
& Signature
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Privacy and Personal Information Protection Notice
This information is voluntarily required to process your request. Your application will be retained in Council’s Records
Management System and disposed of in accordance with the Local Government Disposal Authority. Your personal
information can be accessed and corrected at any time by contacting this Council.
Property Number
Property Address
Rates
Water
(Please Tick for account type)
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Parent category: Financial