Pre-Authorized (PAP) Changes - Water Account

This form allows you to change the details of your Pre-Authorized (PAP) Chequing Plan for Water Account.

Notice of Collection of Personal Information

Personal information on this form is collected under the legal authority of Municipal Act, 2001. This information is collected and maintained for the purpose of sending out electronic mail billing. Questions or concerns about the collection of this information can be directed to the Clerk at 4305 Hamilton Road, Dorchester ON N0L 1G3, Phone: 519-268-7334 ext 254 or clerk@thamescentre.on.ca 

I/We hereby authorize my/our Financial Institution to debit my/our account as indicated on void cheque for all payments payable to the Municipality of Thames Centre.

I/We accept the terms and condtions herein defined on reverse and authorize the Municipality of Thames Centre to begin deductions for payment of my/our tax and or water account(s) for the amount specified.  I/We ensure that the funds will be available to cover withdrawal and that insufficient funds will result in finance charges as applicable, and possibly cancellation of my/our enrolment in the payment plan.

This agreement may be deemed null and void upon any payment returned by the banking system.

This authority is to remain in effect until cancelled by either myself/us or the Municipality of Thames Centre by written notification.  If not cancelled, this authority will be automatically renewed for all future years.

If more than one signature is required for withdrawals against the account number specified, all authorized signatures must be given.