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Pre-authorized Debit Plan Agreement

Please complete the details below to be enrolled in the Pre-authorized payment plan.

Please take note of the following:

Taxes withdrawal on the 10th of every month excluding December.
Utilities withdrawal on the last business day of every month

Start Date:

Please select the account(s) you would like to enroll in Pre-auth

Property Taxes - Regular Program

Utilities - Water & Sewer

Property Taxes - Arrears Program

Roll Number (19 digit starting with 15-31)

Utility Account Number:

Last Name:

First Name:

Phone Number:

E-mail Address

Property Address

Street Address:

Po Box Number:

City:

Province:

Postal Code:

Mailing Address

Street Address:

Po Box Number:

City:

Province:

Postal Code:

Please attach a copy of your void cheque or pre-authorized withdrawal form from your bank

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

UTILITIES: I/we authorize my/our financial institution and the Township of Havelock-Belmont-Methuen to begin deductions as per my/our instructions for monthly recurring payments, for all charges arising under my/our utility account on the last business day of each month. This authority is to remain in effect until the Township has received written notification from me/us of its change or termination at least ten business days before the next debit is scheduled. By placing a signature on this agreement I/we acknowledge that I/we have read, understand, and agree to all of the terms of the pre-authorized debit plan.

TAXES: I/we authorize my/our financial institution and the Township of Havelock-Belmont to begin deductions as per my/our instructions for monthly recurring payments, for all charges arising under my/our property tax account on the 10th of each month excluding December. This authority is to remain in effect until the Township has received written notification from me/us of its change or termination at least ten business days before the next debit is scheduled. By placing a signature on this agreement I/we acknowledge that I/we have read, understand, and agree to all of the terms of the pre-authorized debit plan.

Date:

Signature of Account Holder:

Clear

Signature of Joint Account Holder:

Clear

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