Pre-Authorized Debit Plan Application Form

Pre-Authorized Debit Plan Application

Part 1 – Customer Information

Applicant Name:(Required)

Property Address:(Required)

Street Address City Province Postal Code

Daytime Phone:(Required)

Email:(Required)

Part 2 – Bank Account Information

A void personalized check must be attached to this form for new applications and change of banking information.

Upload void cheque (or equivalent information)

Max. file size: 512 MB.

Select ONE of the following:(Required)

VOID personalized cheque is attached – for new applicant(s) or change of banking information

Use existing Banking Information on file – for existing participants on

Monthly Pre-Payment to Property Tax Roll #(Required)

In the amount:(Required)

Monthly Pre-Payment to Utility account #(Required)

In the amount:(Required)

Effective Date:(Required)

**CURRENT AND PRIOR YEAR PROPERTY TAXES/UTILITIES MUST BE PAID IN FULL PRIOR TO ENROLLING**(Required)

New

Change Amount

Change Bank Account

Cancel

Part 3 – Pre-Authorized Debit Details

Signature(s) of Bank Account Holder(s)(Required)

Print Name(s) of Bank Account Holder(s)(Required)

Date(Required)

Registered Owner information

Fill out if it is different than the Bank Account Holder’s information

Signature(s) of Registered Owner (if different than Bank Account holders info)

Print Name of Registered Owner (if different than Bank Account holders info)

Date Signed by Registered Owner

Input if registered owner is different than the bank account holder’s detail and requires secondary signatures.

Terms & Conditions(Required)

I have read Pre-Authorized Debit Plan Terms & Conditions

Personal information requested on this form is collected under the authority of Section 26 of the Freedom of Information and Protection of Privacy Act, as amended. The information gathered will be used to deliver or evaluate the program or activity of the Village of Anmore that is associated with this form. Questions about the collection, use, and disclosure of this information should be directed to village.hall@anmore.com