Required fields are marked with asterisks (*)

Pre-Authorized Rent Payment Plan Authorization Form

All fields labeled with a star are mandatory and must be completed before your application may be submitted.

Residential Information

First name

Last name

Street number

Street name

Unit number

City

Postal code

Personal Phone number

Work phone number

Email address

Re-enter email address

I would like to:

Change my banking information for my pre-authorized rent payment plan

Terminate my pre-authorized rent payment plan

Applicant consent to terms below

By checking this box, I agree to the "Terms of the Housing and Homelessness Department Pre-Authorized Rent Payment Plan".

Terms

I hereby certify that the banking information given above is correct and I am the person responsible to make this decision. Additionally, I authorize The Corporation of the City of Brantford to receive rental payments by direct deposit to the banking information provided. This authorization will remain in effect until written notice is submitted to cancel or update the banking details. Please allow up to 10 business days for any changes to take effect.

Name of account holder 1

Dated

Name of account holder 2

Dated

Privacy Notification and Consent

Personal information contained in this form or in any attachments is collected by the City of Brantford, pursuant to the Housing Services Act, 2011, Freedom of Information and Protection of Privacy Act or the Municipal Freedom of Information and Protection of Privacy Act and will be used for the purposes of a pre-authorized rent payment plan and/or making eligibility decisions for housing assistance and/or social assistance subsidies. I/We consent to the ongoing use and disclosure of my/our personal information as described above for the purposes of social housing and/or social assistance support decisions as may be necessary. Further, I/We acknowledge I/We have read and understand this consent.