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Belleville Water

Pre-Authorized Payment Plan Application

In Accordance with By-law 2024-201

Belleville Water Account Number

Exact Payment Plan - I/We authorize Belleville Water to debit my/our bank account on the DUE date for payment on my Belleville Water account. This authorization is for regular bills and any final bills.

Equal Payment Plan - I/We authorize Belleville Water to debit my/our bank account one monthly amount on the date I/we selected below. The amount may be adjusted upon notification to me by Belleville Water due to changes in my consumption pattern and or rates or if I/we move to another residence.

The treatment of each payment shall be the same as if I/We had personally issued a cheque or bank authorization form authorizing payment and debit this amount to my/our account.

I/We Agree

Clear

I/We acknowledge that CANCELLATION of this plan must be requested 15 days prior to the next deduction.

I/We acknowledge that a $40.00 SERVICE CHARGE will be applied to the account for any/all pre-authorized payments not honored by the bank in accordance with By-law 2024-201.

Belleville Water may cancel the continuation of the plan if two installments fail to be honored by the bank in accordance with By-law 2024-201.

I/We Agree;

Clear

I/We have attached a personal void cheque/bank authorization, (any account that is a joint bank account must have both/all signatures on this form) indicated below the plan that I/We wish to participate in.

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 debit that is not authorized or is not consistent with this PAP agreement. To obtain a form for a reimbursement claim, or for more information on my/our recourse rights, I/We may contact my/our financial institution or visit http://www.cdnpay.ca

Personal Void Cheque / Bank Authorization attachment

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Payment Options (Select only one)

Exact Payment Plan

Equal Payment Plan - Residential Only

Payment date (For monthly deductions only)

1st business day

15th day of month

25th day of month

Service Type

Personal

Business

Name of Applicant

Name of Co-Applicant

Complete Property Address

Mailing Address; if different from above

Telephone (Residence)

Telephone (Business or Alternate)

Email Address:

Signature of Applicant

Clear

DATE (MM/DD/YYYY)

Signature of Co-Applicant

DATE (MM/DD/YYYY)

Personal information on this form is collected under the authority of the Municipal Act 2001, SO 2001, c25 will be used to process your Pre-authorized Payment Plan Application. Questions about the collection of this personal information only should be directed to the Office Manager of Water Customer Serivce, Finance Department, 169 Front Street, Belleville, ON K8N 2YB. 613-967-3200 ext. 2249