PRE-AUTHORIZED PAYMENT CANCELLATION

Required fields are marked with asterisks (*)

PRE-AUTHORIZED PAYMENT CANCELLATION

Taxation Roll Number

DATE (MM/DD/YYYY)

Property Owner Name;

Property Address;

Email Address;

Current Bank

Effective Date of Cancellation

Plan Type - Monthly or Instalment

Additional Comments

Applicants Signature

Co-Applicants Signature

Note: If your application is setup on a Joint Bank Account, the Co-Applicant must also sign for this request to be processed.

Please complete this form and print.

Submit your completed and signed form:

City of Belleville Taxation Department

169 Front Street

Belleville, ON K8N 2Y8

Fax this form: 613-967-3206

Email: tax.info@belleville.ca

Personal information on this form is collected under the authority of the Municipal Act 2001, SO 2001, c25 will be used to process your request. Questions about the collection of this personal information only should be directed to the Manager of Taxation, Taxation Department, 169 Front St., Belleville, ON 613-967-3241. For assistance in completing this form, please call (613)967-3243.