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Change or Cancellation of Pre-Authorized Payments

City of Brantford By-Law Number 53-94 (As Amended).

Roll number (2906-999-999-99999-0000)

Account number

Street number

Street name

Unit number

Property owner name(s)

Re-enter email

NOTICE OF BANK ACCOUNT CHANGE

We require five (5) business days notice prior to the next scheduled payment withdrawal, to change banking information.

Do you want to change bank account?

Yes

REQUEST FOR CANCELLATION

I / we hereby wish to cancel participation in the Pre-Authorized Payment plan, effective as of

Notice of Cancellation must be received at least five (5) business days prior to the next scheduled payment withdrawal, to ensure that the next payment is cancelled. Payments withdrawn without the required advance notice will not be refunded.

REQUEST FOR CHANGE OF MONTHLY PAYMENT DATE

Change to

Monthly 1st PAP Plan

Monthly 15th PAP Plan

Notice of change of payment date must be received at least five (5) business days prior to the next scheduled payment withdrawal, to ensure that the next payment is withdrawn on the new date requested.

Should you want to change to Due Date Plan or Self-directed payment plan, a new pre-authorized payment application form is required to be submitted.

ACKNOWLEDGEMENT

If more than one signature is required on your cheques, all persons must agree on this form.

I (All) agree

Yes