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Pre-Authorized Water Payment Plan Enrollment

Are you Property Owner or Tenant?

Property Owner

Tenant

Property Address (Street # and Street Name)

Unit/Suite #

Effective Date

Water Account Number

Property Owner Last Name

Primary Telephone Number

Alternate Telephone Number

Email Address

Please enter your 'Void Cheque' information below. Line of Credit cheques are not accepted.

Void Cheque Example

Transit Number

Financial Institution Number

Account Number

Please attached a copy of your cheque. Line of Credit Cheques are not accepted.

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I/We authorize the Town of Whitchurch-Stouffville to begin deductions for payment of my/our water account.

I/We ensure that the funds will be available to cover the withdrawal. Insufficient funds will result in service charges as applicable and possible cancellation of my/our enrollment in the payment plan.

This authority will remain in effect until cancelled by either myself or the Town of Whitchurch-Stouffville with at least fourteen (14) days written notice.

I/We have certain recourse rights if any debit does not comply with this agreement. For example, I/We have the right to receive reimbursement for any debit that is not authorized or is not consistent with the PAD agreement. To obtain more information on my/our recourse rights, I/we may contact my/our financial institution or visit www.cdnpay.ca.

I/We have agreed to the above statement.

Yes

Please sign to acknowledge your statements are true and accurate

Clear

Name of Signature

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Pre-Authorized Water Payment Plan Enrollment

I/We authorize the Town of Whitchurch-Stouffville to begin deductions for payment of my/our water account.

I/We ensure that the funds will be available to cover the withdrawal. Insufficient funds will result in service charges as applicable and possible cancellation of my/our enrollment in the payment plan.

This authority will remain in effect until cancelled by either myself or the Town of Whitchurch-Stouffville with at least fourteen (14) days written notice.