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Customer Pre-Authorized Debit (PAD) Agreement

First Name

Last Name

Mailing Address:

City /Town

Postal Code:

Phone number

Email address

E-Billing

Would you like to receive your water/sewer and/or tax bill to the email provided above?

Yes, taxes and water/sewer.

Yes, taxes only.

Yes, water/sewer only.

No thank you.

Service Address in Saugeen Shores:

Payment Plan Options

Which services would you like to register for pre-authorized debit?

Water and Sewer

Property Tax

Financial Information

Please see the example image below for where to find your financial information on your cheque.

Please note failure to provide correct banking information may result in a $25 fee being charged.

Financial Institution Name:

Financial Institution Number:

Transit Number:

Account Number:

Upload a copy of a void cheque or pre-authorized debit form from your banking institution.

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By submitting this form to the Municipality of Saugeen Shores, I/we authorize the Town of Saugeen Shores to debit the bank account at the above noted financial institution for the payments indicated above.

Authorizing Name(Type the Name of the person submitting the form)

Additional questions or comments:

This Pre-Authorized Debit (PAD) Agreement may be revoked at any time subject to providing notice at least 10 business days before the next debit is scheduled. To obtain a sample cancellation form, or for more information on your right to cancel a PAD Agreement, contact your financial institution or visit www.payments.ca

You have certain recourse rights if any debit does not comply with this this agreement. For example, you have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAD Agreement. To obtain more information on your recourse rights, contact your financial institution or visit www.payments.ca