Pre-Authorized Payment Plan Application Form - Water and Sewer Account

Instructions:

Please complete all sections in order to authorize the Township of North Stormont to take payments directly from your account.
Please agree to the Terms and Conditions at the bottom of this form.
Please send a void cheque to the Township Office by mail / drop off to 15 Union Street, PO Box 99, Berwick OK K0C 1G0 or fax to 613-984-2908.

Option 1: Withdrawal on the due date. Only accounts with no arrears may enroll.
Option 2: 12 monthly installments, withdrawn on the first business day of each month. Interest at the rate of 1.25% per month is applicable with this option.

Option 1

Option 2

Water / sewer account no:

Name(s):

Property address:

City/Town:

Postal code:

Telephone #:

Email address

In order to complete your application please send a void cheque to the Township Office by mail / drop off to 15 Union Street, PO Box 99, Berwick ON K0C 1G0 or fax to 613-984-2908.

If you require assistance, please contact the Township office at 613-984-2821 ext.221

I solemnly declare that all the statements contained in this application and all the supporting documents are true; and agree to the Pre-Authorized Payment Plan's terms and conditions.

Terms and Conditions

I(we) authorize the Township of North Stormont (Payee) to debit my(our) account as indicated on the attached “Void” cheque, or account information provided by a bank official, under the terms and conditions agreed to by me(us) with the Payee until such time as written notice to the contrary is given.
I(we) acknowledge the delivery of my(our) authorization to the Payee constitutes delivery by me(us) to the branch of the financial institution at which I(we) maintain an account, and that such financial institution is not required to verify that the payment(s) are drawn in accordance with this authorization.
I(we) will notify the Payee in writing of any changes in the account information or termination of this authorization 14 days prior to the next due date of the pre-authorized debit.
A service charge will be applicable (and added to my (our) utility account) in the event any payment is not completed by the financial institution due to insufficient funds or for any other reason.
The Payee may cancel or suspend enrollment in the pre-authorized payment plan after two returned payments.
I(we) guarantee that all persons whose signatures are required to sign on the account have signed this authorization below.
I(we) agree to comply with the Rules of the Canadian Payment Association or any other rules or regulations which may affect the services described herein, as may be introduced in the future or are currently in effect and I(we) agree to execute any further documentation which may be prescribed from time to time by the Canadian Payments Association in respect of the services described herein.
You, the payor, may revoke your authorization at any time subject to providing 14 days notice in writing to the payee. To obtain a sample cancellation form or for more information on your right to cancel a Pre- Authorized Payment Plan, contact your financial institution or visit www.cdnpay.ca.
I(we) understand and agree to the foregoing terms and conditions.
You have certain recourse rights if any debit does not comply with the agreement. For example, you have the right to receive reimbursement for any debit that is not authorized or is not consistent with the Pre-Authorized Payment Plan Agreement. To obtain more information on your recourse rights, contact your financial institution or visit www.cdnpay.ca

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Pre-Authorized Payment Plan Application Form - Water and Sewer Account