Rates Direct Debit application form

RATES DIRECT DEBIT APPLICATION FORM

For further information or questions regarding this form, please contact Council via 9911 6555.

Applicant Details

Applicant First Name *

Applicant Surname *

Current Mailing Address *

Current Mailing Suburb *

Current Mailing Postcode *

Email *

Contact Number: *

Please choose one *

New ApplicationReplace Existing Application

Details of the Account to be debited – SAVINGS OR CHEQUE ACCOUNT ONLY

Name of Financial Institution: *

Branch: *

Name(s) of Account Holders: *

BSB Number: *

Account Number: *Do not enter credit card number

Property Details

Property Address: *

Property Suburb: *

Property Postcode: *

Property ID: *

Note: A SEPARATE APPLICATION IS REQUIRED FOR EACH PROPERTY

Payment Details

I/We wish to nominate the following method of payment: *

Full PaymentInstalment PaymentsPeriodical payment -Weekly amount (Every Thursday)Periodical payment -Fortnightly amount (Every 2nd Thursday)

Full Payment (total yearly amount stated on Rates Notice – debited on 31 August)

Instalment Payments (debited on 31 August; 30 November; 28 February; and 31 May)

Periodical Payments (under agreed payment arrangement)

Please specify amount per week *

Please specify amount per fortnight *

Applicant declaration

I/We authorise City of Canada Bay (207021) to arrange for funds to be debited from my/our account at the financial institution identified below, and as prescribed through the Bulk Electronic Clearing System (BECS). This authorisation is to remain in force in accordance with the terms described as per the Terms and Conditions.
I/We will advise City of Canada Bay Council of the cancellation of this authority should I/we wish to stop paying by this method, or on sale or transfer of the property from my/our possession, and will not hold City of Canada Bay Council responsible for any action arising from my/our failure to do so.

Applicant Signature *

Draw signature|Type signatureClear

Date signed *