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Water - Pre-Authorized Payment Plan Enrollment

Are you Property Owner or Tenant?

Property Owner

Tenant

Water Account Number

Effective Date

Property Address (Street # and Street Name)

Unit/Suite #

Primary Telephone Number

Alternate Telephone Number

Email Address

Please attach a copy of your cheque/direct deposit form. Line of Credit Cheques are not accepted.

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

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 am signing as authorized representative for all owners of the property

Agree

Please sign to acknowledge your statements are true and accurate

Clear

Name of Signature

Collection of personal information

Personal information contained in this form is collected under the authority of Municipal Act, 2001 and will be used for the purpose of updating your account information. Questions about this collection should be directed to the Revenue and Taxation department, Town of Whitchurch Stouffville, 111 Sandiford Drive, Stouffville ON L4A 0Z8, Telephone: (905)640-1900,
email: revenue@townofws.ca