[PDF] Water Authorization Form for Pre-Authorized Payment Plan





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FOR OFFICE USE ONLY

DATE RECEIVED: RECEIVED BY:

(Staff Initials)The 3 steps to starting your plan...

1 Fill out this form

2 Attach a voided cheque

3 Fax, mail or drop off to:

Revenue Division

City Hall, 1st Floor,

500 Donald St. E.

Thunder Bay, ON P7E 5V3

Tel: 1-807-625-2255

Fax: 1-807-623-4277

THE CORPORATION OF THE CITY OF THUNDER BAY - REVENUE DIVISIONWater Authorization Form for Pre-Authorized Payment Plan

Name of Owner (s)Water Account Number

Telephone Number

Property Address

This authorization is for (check one) Personal Business BEFORE ENROLLING, PLEASE ENSURE ALL AMOUNTS OWING TO DATE ON

YOUR ACCOUNT HAVE BEEN PAID.

PLEASE CHECK OFF ONLY ONE OPTION AND SIGN:

I am selecting the WATER DUE DATE OPTION.

on due dates in an amount not to exceed my billing. The City of Thunder Bay will mail my water bill to me a minimum of 10 days in

SIGNATURE * DATE

SIGNATURE * DATE

The PAP Plan does not apply to your current billing.

Authorized Payment Plan on your water bill.

OR I am selecting the WATER EQUAL MONTHLY PAYMENT OPTION. based on monthly estimates, being 1/12th of the annual estimated water b illing charges; the sum of which on the last debit, wil l not exceed the

total charges for the year. The City of Thunder Bay will continue to forward quarterly bills every three months.

In order to equalize my account

once a year, I will submit a water meter reading for the last billing period. My pl an will be cancelled if I fail to provide an actual meter reading for this last billing. The annual equalization payment deducted from my bank account will be th e balance on my last bill of the year and the withdrawal date will be the bill due date. Notices will be sent to me 10 days prior to any changes in the monthly withdrawal.

My meter reading is currently on

SIGNATURE * DATE

SIGNATURE * DATE

The PAP Plan does not apply to your current billing.

Authorized Payment Plan on your water bill.

TO BE COMPLETED BY OFFICE: Important Information For Water Equal Monthly Payment Option Initial payment amount and withdrawal date is: $ on

AMOUNT MMM / DD / YYYY

_______________ The month you are required to provide an actual meter reading to equaliz e your account is: _______________ Failure to provide an actual reading will result in account removal from the plan. The approximate withdrawal date for your equalization payment is:

Mid- _______________

* Please provide additional signatures, if more than one signature is re quired on cheques issued against the account. Final bills for ownership changes and when meters are removed are not in cluded in the plan.

There will be a service charge for NSF transactions. Accounts will be removed from the plan after two such transactions.

This authorization may be cancelled or changes may be made at any time i n writing, subject to providing notice two weeks before the

due date of the next withdrawal. To obtain a sample cancellation form, or more information on your right t

o cancel a PAP Agreement, www.cdnpay.ca. You have certain rights if any debit does not comply with this agreement. For example, you have the right to receive reimbursement for

any debit that is not authorized or is not consistent with this PAP Agreement. To obtain more information on your rights, contact your

www.cdnpay.ca.

TB4470(rev01/15)

MMM / YYYY

MMM / DD / YYYY

MMM / YYYY

FOR OFFICE USE ONLY

Section #:

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