Pleaes submit this form if you would like to enroll in pre-authorized payments for taxes, utilities and/or general receivables accounts.
For a joint account, all depositors must sign if more than one signature is required on cheques.
Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif
I/we authorize the Municipality of Northern Bruce Peninsula and financial institution designated (or any other financial institution I/we may authorize at any time) to begin withdrawals as per my/our instructions for payment of charges arising under my/our municipal accounts. This authority is to remain in effect until the Municipality of Northern Bruce Peninsula has received written notification from me/us of its change or termination. This notification must be received in writing at least five business days prior to the next scheduled withdrawal.
By submitting this agreement, I/we acknowledge that I/we have read, understood and agreed to the Customer Agreement and further acknowledge that the Agreement may be subject to change from time to time.
I/we have certain recourse rights if any debit does not comply with this agreement. I/we have the right to reimbursement for any PAP that is not authorized or is inconsistent with this PAP agreement. To obtain further information, I/we may contact my/our financial institution or visit www.payments.ca.
The personal information on this form is collected under the authority of the Municipal Act and will be used only for the purposes of setting up preauthorized payments. Questions concerning the collection of personal information should be directed to the Municipal Clerk at 56 Lindsay Road 5, Lion's Head, ON N0H 1W0 or by telephone at (519) 793-3522 ext. 236.
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