Required fields are marked with asterisks (*)

PRE-AUTHORIZED PAYMENT MODIFICATION

Taxation Roll Number

Name of Applicant

Property Address of Current Owner(Street Number and Name or Legal Address if Property Address not available))

DATE (MM/DD/YYYY)

Email Address

Applicants' Phone Number

Current Bank

Plan Type

Monthly

Instalment

Effective Date of Modification

New Void Cheque

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Additional Comments

Applicant's Signature or Name

Co-Applicants Signature or Name

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

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-Auhtorized Payment Modification request. Questions about the collection of this personal information only should be directed to the Manager of Taxation, Taxation Department, 169 Front Street, Belleville, ON K8N 2Y8 613-967-3241. For assistance in completing this form, please call (613)967-3243.