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Pre-Authorized Debit Application - Taxes

^{I/we authorize the Town of Stony Plain, and the financial institution designated (or any other financial institution I/we may authorize at any time) to begin deductions for monthly regular recurring payments and/or one-time payments from time to time, for payment of all charges arising under my/our Town of Stony Plain tax account(s). Regular monthly payments will be calculated by the Town of Stony Plain and debited to my/our specified account on the 5th or 17th of each month. The Town of Stony Plain will obtain my/our authorization for any other one-time or sporadic debits.}

^{The authority is to remain in effect until the Town of Stony Plain has received written notification from me/us of its change or termination. This notification must be received at least ten (10) business days before the next debit is scheduled at the address listed below. I/we may obtain a sample cancellation form, or more information on my/our right to cancel a PAD agreement at my/our financial institution or by visiting Payments Canada.}

^{The Town of Stony Plain may not assign this authorization, whether directly or indirectly, by operation of law, change of control or otherwise, without providing at least 10 days prior written notice to me/us.}

^{I/we have certain recourse rights if any debit does not comply with this agreement. For example, I/we have the right to receive reimbursement for any PAD that is not authorized or is not consistent with this PAD Agreement. To obtain a form for Reimbursement Claim, or for more information on my/our recourse rights, I/we may contact my/our financial institution or visit Payments Canada.}

^{I/we understand that if 2 (two) consecutive payments are not honoured, the privilege of this program will be cancelled.}

^{In the event that the withdrawal fails to be honoured by the financial institution, the tax account will be charged as if an NSF cheque was drawn, and the normal collection process shall be followed.}

I/we authorize the Town of Stony Plain to debit my/our bank on the 5th or 17th (select one) of each month covering payments due by the undersigned to the Town of Stony Plain for monthly Pre-Authorized Installment Payment Plan for taxes.

I would like my first payment to commence (select month and choose either the 5th or 17th - must be at least 10 days prior to payment date):

Property Address:

Roll Number:

First Name:

Last Name:

Phone Number:

Email address:

Signature (use your mouse or touchscreen in the signature box):

Clear

Today's Date:

You MUST include either a copy of a VOID cheque OR a pre-authorized debit form from your bank in order for your request to be processed. Please attach your VOID cheque or pre-authorized debit form here.

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_{The personal information requested on this form is collected under the authority of Section 33(c) of the Alberta Freedom of Information and Protection of Privacy Act and will be protected under Part 2 of that Act. It will be used for the purpose of administering pre authorized debit. Direct any questions about this collection to: FOIP Coordinator at the Town of Stony Plain 780-963-2151.}