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Pre-Authorized Tax Payment Plan Authorization Form

Are you interested in the enrolling in Pre-Authorized Payment Plan Option? Complete the form below to enroll. Your monthly payment will automatically be withdrawn from your bank account on the first banking day of each month. For inquires call 519 284-2340 Ext 214.

NOTICE OF COLLECTION

The personal information requested on this application form is collected by The Corporation of the Town of St. Marys under the authority of the “Municipal Act” and will be used for the purpose of administering the Pre-Authorized Payment Plan. Questions about the collection and use of this information under the “Municipal Freedom of Information and Protection of Privacy Act” may be made to the Clerk, Box 998 St. Marys ON N4x 1B6 or by telephoning (519) 284-2340 Ext 214.

First Name

Last Name

Property roll number (19 digits)

Property address

Mailing address

Email address

Phone number (Residential)

Phone number (Business)

Agreement

I/we Hereby Authorize my/our Financial Institution to debit my/our account indicated below for estimated property taxes payable for Municipal and Education purposed. This authorization may be cancelled at any time upon written notice by the undersigned or until The Town Tax Department sends a notice of termination. If your payment is returned NSF twice in a row you will be automatically removed from Pre-authorized payment and it will be brought back to good standing before we allow you to resume this form of payment.

Please check the box below to verify that you have read and agree to the terms in the statement above.

I have read, understood and agree to the terms of the statement above.

Please select a payment plan

Quarterly

Monthly

Date

For a joint account, all depositors must sign if more than one signature is required on cheques issued against the account.

Please check the box below to verify that you have read and understand the statement above.

I have read and understand the statement above.

Please upload a scan or photo of a void cheque. If you do not wish to upload a scanned copy, please bring a void cheque to the Municipal Operations Centre at 408 James Street South.

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Pre-Authorized Tax Payment Plan Authorization Form

NOTICE OF COLLECTION