Pre-authorization payment form

Please include an unsigned personalized cheque or bank encode slip for the accounts from which you want the Municipality to withdraw your tax payments. Write “VOID” in ink across the face of the cheque or pre-authorized transaction slip. Please note that if a VOID cheque is not attached to the application or the wrong information is provided, the owner is responsible if the pre-authorized payment is not approved by the bank.

I have read the attached conditions and hereby authorize my financial institution to debit my account based on the City of Quinte West Pre-Authorized Payment Plan for the purpose of paying taxes or water/sewer with respect to the properties noted above

Personal information is being collected on this form under the authority of the Municipality Act and the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA). Please note that personal information collected will form part of the tax or utility records.

I/We agree to the following conditions:

• By enrolling in the Pre-Authorized Payment Plan noted above, I am authorizing the financial institution identified above to withdraw tax or water/sewer payments payable to the City of Quinte West.
• I will notify the City of Quinte West promptly in writing of changes of my financial institution, branch or account. If I am changing ownership of the property and/or need to cancel these pre-authorized payment arrangements, I will notify you in writing giving at least 21 days’ notice.
• The Municipality reserves the right to cancel these pre-authorized payment arrangements with written notice to you.
• If two payments in the same calendar year fail to be honoured, the supervisor may cancel enrolment in the plan. Each payment that is not honoured from my account under the plan will be assessed the Municipality’s current administration fee. I am aware that the Municipality will not retry a returned NSF payment. This payment must be paid by the end of the month in which it occurred.
• I am protected against a loss due to error, fraud or misrepresentation, provided that I notify the financial institution identified above of the problem within 90 days of the date the payment was charged to my account.
• Once I have received notice of the amount of withdrawal, I will check my account statement regularly to confirm that withdrawals are being made in accordance with the authorization I have signed with the City of Quinte West.

Personal information is being collected on this form under the authority of the Municipality Act and the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA). Please note that personal information collected will form part of the tax or utility records.