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Customer Agreement and Authorization Form

Pre-Authorized Debit (PAD) Plan for City of Owen Sound Water / Waste Water

Enter your 11 digit Water Account #:

Please enter the municipal property address:

Please enter the name(s) on the account:

Type of Property:

Personal

Business

Please enter the mailing address (unless it is the same as the address above):

Please enter your primary / preferred telephone number:

Please enter your e-mail address:

Please upload a scanned version of a VOID cheque or pre-authorized debit form from your bank

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

I/We authorize the City of Owen Sound, and the financial institution designated, to begin deductions as per my/our instructions for regular quarterly payments or one time payments from time to time, for payment of all charges arising under my/our City of Owen Sound Utility account(s). The City of Owen Sound will provide written notice of the amount for the debit in advance of the debit date(s). This authorization remains in effect until the City of Owen Sound Water / Waste Water Billing Division has received notification from me/us of its change or termination. This notification must be received at least 10 days prior to the next scheduled debit. I/We have certain recourse rights if any debit does not comply with this agreement. I/We have the right to reimbursement for any PAD that is not authorized or is consistent with this PAD agreement. To obtain further information I/we may contact my/our financial institution or visit cdnpay.ca

Please enter the name of the person authorized to this account, making this submission:

Please indicate you agree with these terms and authorize this pre-authorized debit plan:

I agree and authorize this transaction.

E-Billing

Would you be interested in signing up for e-billing? If you sign up, you will no longer receive paper bills.

Yes - Sign me up for e-billing

No - I do not wish to sign up for e-billing at this time

Authorized Signature(s)

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Authorized Signature

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