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Please fill out and submit the following form in order to authorize Saddle Hills County to debit your bank account for utility or tax payment purposes.

I am filling out this form in order to pre-authorize payments for: (please check the appropriate box(es)

Taxes

Utilities

Customer(s) Name(s):

Mailing Address:

City:

Province:

Postal Code

Telephone:

Email Address:

Utility Account Number(s)

Address ID:

Tax Account Number(s)

Address ID:

Name of Financial Institution (the’Bank’):

Mailing Address:

City:

Province:

Postal Code

Please upload a void cheque, in order for us to verify the account

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Bank Number:

Transit Number:

Account Number:

I/We, the above names Customer(s) authorize Saddle Hills County to debit my/our bank account as indicated above for the monthly utility payment on the last day of the month. The monthly payment amount to be triggered by the utility billing. Saddle Hills County will obtain my/our authorization for any other one-time or sporadic debits.

And/or, I/We, the above names Customer(s) authorize Saddle Hills County to debit my/our bank account as indicated above for the pre-determined tax payment on the 1st or 15th of the month as set out with the taxation clerk. The monthly payment amount to be determined by the taxation department. Saddle Hills County will obtain my/our authorization for any other one-time or sporadic debits.

I/We will notify Saddle Hills County promptly in writing if I/we move the account from one bank or branch to another, or if there is any other change in the account.

This authority is to remain in effect until Saddle Hills County has received written notification from me/us of its change or termination. This authorization may be cancelled at any time upon ten (10) days written notice to Saddle Hills County. I/we may obtain a sample cancellation form, or more information on my/our right to cancel a PAD Agreement at my/our financial institution or by visiting www.cdnpay.ca.

Where the Payor's account agreement requires the signature or two or more signing authorities, the signatures of all such persons are required for the purposes of this authorization.

This authorization is signed with the understanding that failure to provide sufficient funds may result in additional charges that will be the responsibility of the account holder. Failure to provide sufficient funds will cause this agreement to be null and void.

Notice of Collection

Protection of Privacy - The personal information requested on this form is collected under the authority of Section 33 (c) of the Alberta Freedom of Information and Protection of Privacy Act and will be protected under Part 2 of that Act. It will be used for the purpose of addressing issues and concerns raised by members of the public and in case any follow-up information is required. Direct any questions about this collection to: FOIP Coordinator, Saddle Hills County, RR 1, Spirit River, Alberta, Canada, T0H 3G0, 1-888-864-3760.

Date:

Customer's Signature (Please sign below)

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By checking this box, which functions as your legal signature, you confirm that the information provided is as complete and accurate as possible, and that you agree to the terms and conditions of this form

I understand that checking this box constitutes a legal signature

Date:

Customer's Signature (Please sign below)

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I understand that checking this box constitutes a legal signature

Please send me a pdf copy of this form

Yes

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