Pre-Authorized Water Utilities
Payment Application Form
Property Address: _________________________ Account Number: ______________
Name: __________________________________ Owner Tenant
Telephone Number: ________________________ Email Address: __________________________
Mailing Address (if different from the property address):_____________________________________
Type of Service: Personal Business
Due Date Pre-Authorized Payment Plan:
• Under this plan your water bill will be mailed to you as usual. It will advise you of the date
and amount to be withdrawn from your account.
• For any payment not cleared by your bank there will be a service charge plus any applicable
penalty.
• If a bank payment is returned twice during the year, enrolment in the Pre-Authorized Payment
Plan will be terminated.
• An application must be completed for each water-metered account.
• Please note all new applications changes and cancellation requests must be received 30
days before the next payment date. These changes must be in writing and contain the
owner’s signature.
I/we hereby authorize the City of Waterloo, and the financial institution designated, to withdraw payments from my/our bank account
to pay water utilities in the manner indicated. This authority is to remain in effect until City of Waterloo has received written
notification from me/us of a change or termination.
These withdrawals relate to the payment of water and are considered
Personal PAD’s
Name: Name:
Signature: Signature:
Date: Date:
How to Register:
1. Complete the Pre-Authorized Water Utilities Payment Application Form
2. Ensure the form is signed and dated.
3. Mail, fax or email your completed application form and void cheque or a direct deposit form from your
bank with your bank transit number, bank number, and account number to the City of Waterloo Revenue
Services.
City of Waterloo, Revenue Services
100 Regina Street South
PO Box 337 STN Waterloo
Waterloo, ON N2J 4A8
Email: preauthorized@waterloo.ca
Fax: 519-747-8760
To the extent that information collected for water utility constitutes personal information as defined in the Municipal Freedom of Information and
Protection of Privacy Act
, R.S.O. 1990, chapter M.56 as amended, the information is subject to provisions of that act and will be used for the
plied. Questions about the collection of personal information should be directed to the city clerk, Waterloo City Centre,
100 Regina Street South, P.O. Box 337 STN
Waterloo, Waterloo, ON N2J 4A8; Telephone: 519-886-1550
