Please Return to: For more information:
Tax Office tax@guelph.ca
City of Guelph T: 519-837-5605
1 Carden St. F: 519-837-5647
Guelph, ON N1H 3A1 guelph.ca/tax
__________________ _____________________________
CUSTOMER AGREEMENT & AUTHORIZATION FORM
PRE-AUTHORIZED DEBIT (PAD) PLAN FOR CITY OF GUELPH PROPERTY TAXES
TAXES MUST BE UP-TO-DATE TO BE ELIGIBLE FOR ONE OF THE PAYMENT PLANS
STEP ONE - PLEASE SELECT A PLAN:
MONTHLY BUDGET PLAN MONTHLY BUDGET PLAN MONTHLY BUDGET PLAN
Nine (9) Payments Eleven (11) Payments Twelve (12) Payments
January – September January - November January - December
Last banking day of the month Last banking day of the month 15
th
of the month
INSTALMENT ONLY PLAN REQUESTED PLAN START DATE
Four (4) Payments ________ l ________
On the tax due date Month Year
STEP TWO - PROPERTY AND TAXPAYER INFORMATION: (PLEASE PRINT)
Roll Number: 23 – 08 – __ __ __ – __ __ __ – __ __ __ __ __ – 0000
Municipal Address of Property: _________________________________________________________________
Assessed Owner’s Name(s): _________________________________________________________________
_________________________________________________________________
This application is made on behalf of: A Person A Business
Owner’s Mailing Address: _______________________________________________________________________
_______________________ ________________________________________________
(City) (Province) (Postal Code)
Owner’s and Contact’s Email Address: _________________________________________
Owner’s and Contact’s Telephone Number: (__ __ __) – __ __ __ – __ __ __ __
STEP THREE - PLEASE ATTACH A VOID CHEQUE OR BANK LETTER CLEARLY INDICTATING THE INFORMATION BELOW
Branch Transit # (5 digits) Financial Institution # (3 digits) Bank Account #
I/We authorize the City of Guelph, and the financial institution designated, to begin deductions as per my/our instructions for regular monthly recurring
payments or one time payments from time to time, for payment of all charges arising under my/our City of Guelph Property Tax account(s). Regular
monthly payments will be debited on the 15
th
or the last business day of each month. Instalment plan customers will have their payments debited on the
instalment due date. The City of Guelph will provide written notice of the amount for the debit in advance of the debit date(s) This authorization remains in
effect until the City of Guelph Tax Department has received written notification from me/us of its change or termination. This notification must be received
in writing at least 10 days prior to the next scheduled debit. I/We have certain recourse rights if any debit does not comply with this agreement. I/We have
the right to reimbursement for any PAD that is not authorized or is inconsistent with this PAD agreement. To obtain further information I/we may contact
my/our financial institution or visit payments.ca.
STEP FOUR: If multiple signatures are required to issue a cheque or authorize a debit on the bank account being used for the
PAD plan, please ensure they all sign below.
Authorized Signature(s) __________________________________________ Date: _______________________________
Authorized Signature(s) __________________________________________ Date: ________________________________
Personal information is being collected and will be used to administer the pre-authorized debit (PAD) plan for tax payments program. Personal
information, as defined by Section 2 of the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA), is collected under the authority of
the Municipal Act, 2001, and in accordance with the provisions of MFIPPA. If you have questions about the collection, use or disclosure of this personal
information please call 519.822.1260 extension 2349 or email privacy@guelph.ca
