Required fields are marked with asterisks (*)

Pre-Authorized Payment Plan Agreement

In order to enroll in the Pre-Authorized Paymen Plan the following criteria must be met:

All arrears must be paid in full prior to application approval
Complete the below agreement
Provide a void cheque (available for upload as part of this agreement)

Please select which plan you wish to participate in

Taxes - Installment (full amount on due date)

Taxes - Monthly

Water - Installment (full amount on due date)

Water - Monthly

First Name

Last Name

Email Address

Phone Number

Property Address

Please enter your roll number

Bank Name

Bank Institution Number

Bank Transit Number

Bank Account Number

I/We hereby authorize the Township of Laurentian Valley to debit my/our bank account for the payment of my/our realty taxes and/or utility billing in electronic form from the Banking Institution named above.

I/We agree

This authorization may be cancelled by submitting a PAP cancellation form fifteen (15) days prior to withdrawal date.

I/We agree

I/We hereby authorize the Township of Laurentian Valley to increase/decrease the amount in accordance with our Municipal By-law as amended.

I/We agree

I/We hereby will inform the Township of Laurentian Valley in writing of any changes to the account information provided above.

I/We agree

The Township of Laurentian Valley reserves the right to remove the account from the Pre-Authorized Payment Plan if payments are in default.

Authorized Signature 1

Clear

Name of Authorized Signature 1

Authorized Signature 2 (if required)

Clear

Name of Authorized Signature 2 (if required)

Provide a void cheque or pre-authorized debit form from your financial institution (please upload with this agreement).

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The information collected on this form is being collected under the authority of Section 342 of the Municipal Act, 2001 as amended and will be used for the sole purpose of applying pre-authorized payments to the relevant account.

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Pre-Authorized Payment Plan Agreement

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