Required fields are marked with asterisks (*)

Pre-Authorized Debit Plan Change Request - Water

I/we authorize the City of Belleville, and the financial institution designated (or any other financial institution I/we may authorize at any time) to begin deductions as per my/our instructions for regular recurring payments on the due date of my/our City of Belleville utility account(s).

My/Our account will be debited on the date and for the amount detailed on my/our bill(s). Where payment(s) have already been made against my/our account, which have reduced the amount owing as detailed in my/our utility bill(s), only the amount still owing will be debited to my/our account.

This authority is to remain in effect until the City of Belleville Water/Waste Water billing department has received written notification from me/us of its change or termination. This notification must be received at least 10 business days before the next debit is scheduled at the address provided below.

First Name

Last Name

First Name of Co-Applicant

Last Name of Co-Applicant

Email Address

Water Account Number

Type of Service

Personal/Residential

Business/Commercial

Address

City/Town

Postal Code

I would like to

Start a new pre-authorized debit plan

Change bank account information on my pre-authorized debit plan

Cancel an existing pre-authorized debit plan

* To be eligible to enroll in any of our PAP Plans there must be no outstanding amount/arrears on your utility account

Authorized Signature

Clear

First and Last Name

For assistance, or further information please call 613-966-3657 or email WaterFinanceGeneral@belleville.ca