Required fields are marked with asterisks (*)

Township of Mapleton Pre-Authorized Payment Form:

Property Tax Roll # (If known):

Property Address:

Owner Name(s):

Phone #:

Email:

Effective Date:

Frequency of Withdrawal:

On DUE DATE (4 times/year)

1st of EVERY MONTH (or next business day)

BANKING INFORMATION:

Financial Institution Number

Branch/Transit Number

Account Number

Void Cheque or Direct Deposit Form:

Browse…

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

Agreement Details:

I/we authorize the Township of Mapleton and the financial institution designated (or any other financial institution I/we may authorize at any time) to begin deductions as per my/our instructions for regular recurring payments and/or one-time payments from time to time, for payment of all charges arising under my/our Township of Mapleton Property Tax/Water/Sewer account(s). Regular payments for the full amount of services delivery will be debited to my/our specified account on the date indicated. The Township of Mapleton will provide 10 days written notice of the amount of each regular debit. The Township of Mapleton will obtain my/ our authorization for any other one-time or sporadic debits.

This authority is to remain in effect until the Township of Mapleton has received written notification from me/us of its change or termination. This notification must be received at least 10 business days before the next debit is scheduled at the address provided below. I/We may obtain a sample cancellation for, or more information on my/our right to cancel a PAD agreement at my/our financial institution or by visiting www.cdnpay.ca.

Signature:

Clear

Date: