Direct Debit Request

Document Sample
Direct Debit Request Powered By Docstoc
					                                                                                             Cowra Shire Council
                                                                                             Private Bag 342
                                                                                             Cowra NSW 2794
                                                                                             ABN: 26 739 454 579
                                                                                             Phone: 02 6340 2000
                                                                                             Fax: 02 6340 2011

                                                                                Direct Debit Request
           Request and Authority to debit the account named below to pay Cowra Council
Request and Authority       Surname or Company Name: _________________________________
to debit
                            Given Names or ACN/ARBN: __________________________(“you”)
                            request and authorise Cowra Shire Council [Debit User Identification Number 157603] to
                            arrange for any amount Cowra Shire Council may debit or charge you to be debited through
                            the Bulk Electronic Clearing System from an account held at the financial institution
                            identified below subject to the terms and conditions of the Direct Debit Request Service
                            Agreement [and any further instructions provided below].

Insert the name and         Financial Institution Name: ___________________________________
address of financial
                            Address: ________________________________________________
institution at which
account is held
Insert details of account   Name of Account: _________________________________________
to be debited
                            BSB Number: |___|___|___| - |___|___|___|

                            Account Number: |___|___|___|___|___|___|___|___|___|

Acknowledgment              By signing this Direct Debit Request you acknowledge having read and understood
                            the terms and conditions governing the debit arrangements between you and Cowra
                            Shire Council as set out in this Request and in your Direct Debit Request Service

Payment Details                      [The maximum amount to be debited at any one time is:
                            $ |___|___|___| - |___|___|
                                                      (amount in words)
                            The first debit may be made on ___ / ___ / ___and thereafter at weekly /
                            fortnightly / monthly / rate instalment intervals – until further notice
                            ** instalment amounts in accordance with current Rate Notice **
Account/s to be paid:       Rate Assessment Number:
                            Water Debtor Number:
                            Private Works Debtor Number:
Insert your signature       Signature: _______________________________________________
and address                 (If signing for a company, sign and print full name and capacity for signing eg. director)
                            Address: ________________________________________________
                            Date              ___ / ___ / ___           Phone ____________________

Shared By:
Description: Direct Debit Request