Fillable Pre-Authorized Utility Bill Payment

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Pre-Authorized Utility Bill Payment

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Country of origin: CANADA
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Application
Pre-Authorized Utility Bill Payment
22-0046 2015-02 Page 1 of 2
Applicant Information
Utility Account Number (20 digits):
Property Address:
Name(s):
Signature*:
Signature*:
My/our application is for Personal or Business PAD service
* By signing this form you agree to the terms and conditions listed on page 2. Please provide additional
signatures, if more than one signature is required on cheques issued against the account. Please review,
print sign and return your application form.
Date (YYYY/MM/DD): Date (YYYY/MM/DD):
Telephone (Day):
Telephone (Day):
Financial Institution Information
Please attach a void cheque or have your bank/financial institution complete the following.
Financial Institution (FI) Transit Number:
FI Number:
Account Number:
FI Name:
FI Address:
Name of FI Officer:
FI Officer Title:
Signature of FI Officer:
FI Officer Phone Number:
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Application
Pre-Authorized Utility Bill Payment
The personal information on this form is collected under the authority of the City of Toronto Act, S.O. 2006, Chapter
11, Schedule A, s. 261, s. 264 and Ontario Regulation 594/06: and the City of Toronto Municipal Code, Chapter 849
(Water and Sewage Services and Utility Bills). The information is used to administer the Pre-Authorized Utility Bill
Payment Program. Questions about this collection can be directed to the Manager, Customer Service, Revenue
Services, 5100 Yonge Street, Toronto, Ontario, M2N 5V7 or by phone at 416-338-4829.
22-0046 2015-02 Page 2 of 2
Conditions
I/we authorize the City of Toronto Revenue Services Division (herein referred to as the "City") and the
financial institution designated (or any other financial institution I/we may authorize at any time) to begin
deductions as per my/our selections on this application.
I/we understand that the City will issue a utility bill indicating the amount and the date of withdrawal from
my/our financial institution account. The City will notify me/us in writing at least 10 days prior to the date of
the withdrawal if the amount is to be increased. I/we can waive our right to this notice requirement if
I/we authorize the city verbally.
I/we understand that I/we may cancel my/our PAD agreement by providing a signed written notice to the
City at least 15 days before the next debit is scheduled and the notice must be sent to the City address
indicated on this form. I/we also understand that the City may terminate this authority if any of my/our
payments are returned by my/our financial institution as per the conditions of enrolment in the City's Pre-
Authorized Utility Bill Payment Program. I/we may obtain a sample cancellation form or more information
on my/our right to cancel this PAD agreement at my/our financial institution or by visiting
www.cdnpay.ca,
the Canadian Payments Association website or
http://www.toronto.ca/utilitybill, the City's website.
I/we have certain recourse rights if any debit does not comply with this agreement. For example, I/we 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/our recourse rights,
I/we may visit
www.cdnpay.ca or may contact my/our financial institution.
Important Information
The application date will be the date received if not completed.
You will receive written confirmation of your enrolment in this program within 30 days of receipt of your
application form.
Financial institution/banking information is not printed on the bills.
Line of credit accounts and credit card cheques cannot be used for pre-authorized payments.
The payment plan is not transferable to another account.
You must complete, sign and return this full form to register.
Submit Applications and Documents
Mail: Revenue Services
Box 2510, Terminal A
Toronto, Ontario M5W 1H2
Fax: 416-696-4219
(sending personal information by fax is not a secure means of transmission)
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Pre-Authorized Utility Bill Payment

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Completed 4 January 2021

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