REPLACEMENT CHEQUE FORM

Pre-Authorized

Tax Installment Payment Plan

I/We wish to change the bank account my/our pre-authorized payments are withdrawn from.

First Name:

Last Name:

Business Names (if applicable):

Phone Number:

Email Address:

Property Address:

Roll Number:

Effective Date (must be at least 10 business days prior to your next scheduled payment date):

Signature of Account Holder (Use your mouse or touchscreen in the Signature Box):

Clear

Today's Date:

Please attach either a copy of a VOID cheque or pre-authorized debit form from your Financial Institution.

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^{This personal information is being collected for the Town of Stony Plain under the authority of Section 33c of the Freedom of Information and Protection of Privacy (FOIP) Act and will be used to collect information regarding Pre-Authorized Tax Payment Plan Replacement Cheque form. The personal information provided will be protected in accordance with Part 2 of the Act. If you have any questions regarding the collection, use and disclosure of personal information, please contact the FOIP Coordinator at 780-963-2151.}