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Water and Wastewater – Pre-Authorized Payment Plan Change

Name:

Telephone number:

Email Address:

Account Number:

Municipal Address (Including Postal Code):

Please choose one of the following options to change your pre-authorized plan:

Bank information has changed (attach new 'VOID' cheque)

Please attach a new VOID cheque

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Effective Date:

I hereby authorize the Municipality of Port Hope to make the appropriate adjustment(s) to my pre-authorized plan as identified above.

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Date:

Personal Information on this form is collected under the authority of the Municipal Freedom of Information and Protection of Privacy Act, R.S.O. 1990 c. M56, as amended. Inquiries about the collection of personal information should be directed to the Municipal Clerk.

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Water and Wastewater – Pre-Authorized Payment Plan Change