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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:

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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.

Financial Institution: (*)
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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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