Banking Information Change Request Form

Required fields are marked with asterisks (*)

Pre-authorized Payment Application Banking Information Change Request Form

Please change the banking information for my Pre-Authorized Tax Payment as per the attached VOID cheque.

Note: Banking information changes must be received in our office 10 business days prior to the next withdrawal in order to process the next payment.

Property roll number

Name:

Property Street Address:

Town

Province

Postal Code

Phone Number

Email Address

Effective Date for this change

I/we hereby authorize the corporation of the town of arnprior to debit my/our account per attached void cheque, for all estimated taxes applicable to the above noted assessed property. This authorization may be cancelled at any time upon notice by me/us.

(For joint accounts all depositors must sign if more than one signature is required on cheques issued against the account)

Signature of Account Holder

Clear

Date

Signature of Joint Account Holder

Clear

Date

Please attach a void cheque

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

Personal information on this form is collected under the authority of the Municipal Freedom of Information and Protection of Privacy Act, R.S.O c.M.56 as amended and will be used to document delegates names, addresses, for pre-authorized payments. Inquiries may be directed to the Town Clerk by telephone at 613-623-4231 ext. 1817 or by email at clerk@arnprior.ca.

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