Required fields are marked with asterisks (*)

Pre-authorized Payment Application Form

Your account must be up to date and in good standing to register.

Should a payment be returned by the financial institution, NSF charges will be added to the property owner’s account and interest and penalty charges will apply.

Property roll number

Name:

Property Street Address:

Town

Province

Postal Code

Mailing Address (If different than property address)

Phone Number

E-mail Address

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

I/We agree to (Please choose 1)

10 month payment plan

due date payment plan

Please attach a void cheque

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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.