Pre-Authorized Payment Form

Request*field type radio button
RequestFirst Time SetupChange in BankingChange in Payment Plan
Type of Billing*field type checkbox
Type of BillingTax BillingUtility Billing
*Please see 'Additional Information' page for details on the plans.
Tax Billing*field type radio button
Tax BillingInstallment PlanMonthly Plan
Utility Billing*field type radio button
Utility BillingBilling Due DateMonthly Plan
Name*field type single line
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Additional Namefield type single line
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Address*field type single line
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Phone*field type number
Email*field type email
Tax Account #*field type single line
3954-###-###-#####-0000
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Utility Bill #*field type single line
###-#######-###
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Effective Date*field type date

Financial Institution Information

Financial Institution*field type single line
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Branch Address*field type single line
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City*field type single line
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Province*field type single line
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Postal Code*field type single line
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Bank #*field type single line
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Transit #*field type single line
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Account #*field type single line
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Upload*field type file upload
Please include a copy of your Void Cheque OR Pre-Authorized Debit Form
Drop files here
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I/we, as the above account holder(s), do hereby authorize the Municipality of North Middlesex and my/our financial institution to debit my/our account for payment of utility charges. The authorization may be cancelled at any time upon written notice by me/us. (Signatures on cancellation should be the same as those on this plan request.)
Signature*field type signature
Signature*field type signature

TERMS AND CONDITIONS:
1.     The customer certifies that the bank account is in good standing with sufficient funds to cover pre-authorized payments as they become due. All signatures required on the bank account must be on this agreement.
2.     The Municipality of North Middlesex will charge $25.00, plus any applicable interest and/or penalties, for any payment returned by the bank for any reason. Two infractions of this condition will remove the customer from this plan without further notice.
3.     We must receive notification of any changes to banking information no later than the 1^st of the month. Please ensure we receive a complete updated agreement prior to this date.
DEFINITIONS:
Monthly Plan (Tax Accounts Only): Payments will be withdrawn from the specified account on the last business day of each month. January to July payments will be based on the prior years tax levy. That amount will be divided by 12 and the resulting number will be rounded up to the next even dollar. The August to December amounts will be determined by taking the current year’s taxes and subtracting the payments that have been made. The remaining amount will be divided equally over the last five months.
Installment Plan (Tax Accounts Only): Payments will be withdrawn from the specified account on the last business day of the months that the installments are due on. The amount of the withdrawal will equal the tax installment due in that month.
Billing Due Date (Water/Sewer Accounts Only): Payments will be withdrawn from the specified account on the same date as the water/sewer billing shows as a due date.
Monthly Plan (Water/Sewer Accounts Only): Payments will be withdrawn from the specified account on the 10^th of each month. Water payments will be determined by taking the amount owing per quarter multiplied by 4 to give the entire years water, subtract any payments already made and then divide by the number of months left in the year to give the total amount owing monthly to bring the account to zero by December 31.

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