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Electronic Fund Transfer (EFT) Authorization Payment Form

RULES AND CONDITIONS OF THE AGREEMENT:

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 this agreement. The Township of Essa does not assume responsibility for receipt of inaccurate banking data. Any outstanding amounts will become due immediately.

2. Should your banking information change at any time, a new Electronic Fund Transfer/Preauthorized Payment Agreement must be completed.

3. You must provide the Township of Essa with written notification of any change in bank accounts or residence.

4. You may revoke/cancel this agreement at any time, within ten (10) days of the due date, by providing written notice to the Township of Essa.

5. You have certain recourse rights if any debt does not comply with this agreement. For example, you have the right to receive reimbursement for any debt that is not authorized or is not consistent with the Electronic Fund Transfer/Pre-authorized Payment Agreement.

Please contact the Township Office at (705) 424-9917 if you require further information

Name of Applicant or Organization

Mailing Address

Email Address

Phone Number

Bank Transit No.

Bank No.

Bank Account No.

Please upload a void cheque or a pre-authorized debit form from your financial institution

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

I hereby authorize the Township of Essa to withdraw payments from my bank account to pay the item due, as indicated, in the following manner: (Check OPTION 1 OR OPTION 2 and complete the required information.)

Option 1 - ONE-TIME PAYMENT

Option 2 - WITHDRAW ALL CURRENT AND FUTURE INVOICED AMOUNTS

Privacy statement

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 purposes for which its collection was intended. Questions about this collection should be directed to the FOI Coordinator at the Township of Essa.

Date of Application

Please sign your application using your mouse or mouse pad

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