Pre-Authorized Payment Plan for Quarterly Water & Sewer Invoice

Please complete this form if you would like to authorize the Township of Essa to debit your bank account for your quarterly Water & Sewer Invoice.

You are required to provide your Utility Account No., and upload a VOID cheque with this application.  If you don't know your utility account number, please contact the Public Works Department at 705-424-9917 extension 114 or 127.

Mandatory fields are marked with an asterisk(*).

Rules and Conditions of Plan

1. There will be a $30.00 handling charge for any payment request that is refused by your bank due to insufficient funds or a closed account.  A second occurrence will automatically cancel your automatic withdrawal arrangements.  The Township of Essa does not assume responsibility for receipt of inaccurate banking data.  Any outstanding amounts will become due immediately.
2. You must provide the Township with written notification of any change in bank accounts or residence, or the sale of your property.  A lawyer's letter is not sufficient.
3. Should your banking information change at any time, a new Pre-Authorized Payment form must be completed.
4. I may revoke/cancel my authorization at any time, within ten days prior to the due date, by providing written notice to the Township of Essa.
5. I have certain recourse rights if any debit does not comply with this Agreement.  For example, I have the right to receive reimbursement for any debit that is not authorized or is not consistent with the PAD Agreement.

Privacy

Personal information contained in this form is collected under the authority of the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA), and will be used only for the purpose for which its collection was intended.  Questions about this collection should be directed to the FOI Coordinator at the Township of Essa.

Authorization

I hereby authorize the Township of Essa to withdraw quarterly payments from my bank account to pay my quarterly Water & Sewer Invoice