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Pre-authorized Payment Agreement
I/We hereby authorize the Town of Tillsonburg to draw amounts from my financial institution for automatic bill payments.
Family or Company Name (In Full):
(*)
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Cycle:
(*)
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Account No:
(*)
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Service Address:
(*)
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Telephone Number:
(*)
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Select Payment Plan Type:
Variable Payment Plan (Actual amount due)
Equal Payment Plan (Residential, SSS customer ONLY)
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I/We authorize the financial institution named below to debit the bank account number named below for all utility payments, payable to the Town of Tillsonburg.
Bank Account No:
(*)
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Transit No:
(*)
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Bank Branch Number
(*)
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I/We will notify the Town of Tillsonburg immediately of any change in bank account or residence. By entering your name/names in the boxes below you are digitally signing this form and agreement.
Full name of applicant:
(*)
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2nd Name of applicant (if applicable):
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Date:
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Tick to confirm:
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