Applicant Name:

Roll Number:

Physical Address:

Home Telephone:

Work Telephone:

Email Address:

Start Date:

(notice of payment adjustment will be sent by mail every 6 months)

Installment Plan: Monthly InstallmentsQuarterly Installments
Installment Due Date: 1st of the month15th of the month

Monthly Installments
The monthly installment plan consists of monthly installments from February to July and the final installment, monthly installment plan consists of August to January. The monthly installments will be withdrawn from your account on the 1 st or the 15th of each month. A notification of the amounts and dates of withdrawals will be sent to you a minimum of twenty (20) days prior to implementation of any changes to your payments.

Quarterly Installments
The quarterly payment plan consists of four installments which will be automatically withdrawn from your account on the date which tax installments are due and in the amount as indicated on the tax bill provided to you for your information.

If you wish to participate in this plan, please complete this form and return it, along with a VOID cheque or direct withdrawal Information Form to the Municipal Office at 2 King St. E or by mail at PO Box 70, St. Charles, ON P0M 2W0. Should you have any questions please contact our office at (705) 867-2032.

A separate form must be completed for each tax roll number.
I hereby authorize the Municipality of St.-Charles, its officers, and agents to withdraw cheques on the above account for payment of municipal taxes on the above-noted property in the amount determined as per policy from time to time.

This authority is to remain in effect until the Municipality of St.-Charles has received written notification from me of its change or termination. This notification must be received at least fifteen (15) days before the next debit is scheduled at the address provided above. I may obtain a sample cancellation form or more information on my right to cancel a PAP agreement at my financial institution or by visiting www.cdnpay.ca.

Signature:

Signature 2 (if joint account):

Date:

I have certain recourse rights if any debit does not comply with this agreement. For example, I have the right to receive reimbursement for any PAD that is not authorized or is not consistent with this PAD agreement. To obtain a form for a Reimbursement Claim or for more information on my recourse rights, I may contact my financial institution or visit www.cdnpay.ca.
Upload Void Check or Withdrawal Form: