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Water Account Pre-Authorization Payment Plan Agreement

Please Select a Plan:

Fixed Amount (monthly withdrawal on the 30th)

Fixed Amount (monthly withdrawal on the 15th)

Installment Amount (full amount of installment withdrawn on due date)

If you selected 'Fixed Amount', you may indicate the amount: $

Unless an amount is specified this amount will be calculated by the Township. Amounts specified that result in less than full payment of all water charges will be subject to 1.25% penalty/interest per month. The Pre-Authorized Payment Plan runs from December to the following November. In the year of enrollment payments are calculated so that the estimated amounts owing by the November payment. In subsequent years payments are recalculated in December based on the prior year's usage and the current water rates in the Fees & Services By-law. Notification will be mailed 10 days prior to any change in the amount being withdrawn.

Effective Date:

Roll Number:

Municipal Address of Property:

Assessed Owner's Name(s):

Telephone:

Email Address:

Financial Institution Name:

Financial Institution Mailing Address:

Please upload a scanned/photographed blank cheque marked 'void', or a pre-authorized bank withdrawal form, obtained from your bank.

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Please indicate the Transit No., Financial Institution No., and Account No., to be debited. These numbers are found on your cheques, on your online banking platform, or can be obtained from your bank representative.

I/We hereby authorize the Township of Georgian Bluffs (herein the "Township") and the financial institution designated (or any other financial institution I/We may authorize at any time) to begin debiting my bank account in accordance with the payment plan selected for payment of My/Our Water Account. Such authorization will remain in effect until I/We cancel this agreement.

I/We agree to provide the Township with written notice a minimum of 14 days notice prior to any changes or cancellation of this Pre-Authorized Payment Plan (PAP). I/We may obtain a sample cancellation form or more information on My/Our right to cancel this PAP agreement at My/Our financial institution or by visiting the Canadian Payments Association website at www.payments.ca.

In the event that any debit request is not honoured by My/Our financial institution for any reason an Administrative charge of $40.00 will be applied against my account. A Returned Item Notice will be sent advising Me/Us of the replacement payment required. If two debits are not honoured in any calendar year Me/Our agreement will be terminated and My/Our account will return to the regular payment schedule, subject to regular penalty and interest charges.

In the event that the Water Rates contained in the Fees & Services Bylaw are amended My/Our account My/Our monthly amounts may need to be adjusted and that notification will be mailed to the address indicated on My/Our Water Account File (10) days prior to this withdrawl.

I/We have certain recourse rights if any debit does not comply with this agreement. For more information on My/Our rights, I/We may visit www.payments.ca or may contact My/Our financial institution.

Your Signature(s) confirms that you have read, understand and agree to the terms and conditions outlined on this page.

Clear

Date:

Signature of Co-Applicant, if applicable:

Clear

Date:

The above signature(s) must be authorized to sign on the bank account provided. If multiple signatures are required to issue a cheque or authorize a debit on the account the same number of signatures is required to process this pre-authorized debit.