Name (family name, given name) _____________________________________________________________________________________________________________________
Utility account number ___________________________________________________________________________________________________
Property address __________________________________________________________________________________________________________________________________
Mailing address (
if different than property address) ______________________________________________________________________________________________
Telephone (________ ) ___________ - ________________________ Fax (
optional) (________ ) ___________ - ________________________
Name of Financial Institution __________________________________________________________________________
Branch Address ___________________________________________________________________________________________________________________________________
Branch Transit No. Financial Account No.
(5 DIGITS) Institution No.
Please include a blank cheque marked “void”.
Please note your first withdrawal will include all
amounts outstanding on your account.
I/We hereby authorize the City of Victoria and the financial institution
designated to debit my bank account indicated for the charges arising
under my City of Victoria utility account. The payment for services will
be debited on the due date specified on the invoice provided.
I/We agree to the terms and conditions listed below.
Signature of Account Holder ____________________________________ Signature of Joint Account Holder (
if applicable) ___________
please print) _____________________________________________ Name (please print) _____________________________________
yy/mm/dd) ________________________________________________ Date (yy/mm/dd) ________________________________________
Terms and conditions of customer’s authorization to the City of Victoria
1. The balance of the utility bill will be withdrawn on the due date specified on the invoice mailed to you. Utility accounts are billed three
times a year (every four months). Please note your first withdrawal will include all amounts outstanding on your account.
2. The customer will notify the City of Victoria of any changes to the customer’s financial institution account information.
3. This authorization may be cancelled at any time by the customer upon seven days written notice to the City of Victoria.
4. The City of Victoria may terminate this pre-authorized agreement should the customer fail to maintain their financial institution
account in good standing. Penalty and services charges will apply to any returned or outstanding payments.
Mail or fax your completed form, along with a void cheque to:
City of Victoria
1 Centennial Square
Victoria, BC V8W 1P6
For further information:
Pre-authorized Payment Plan Agreement
CITY OF VICTORIA
1 CENTENNIAL SQUARE, VICTORIA, BC V8W 1P6
CHEQUE # TRANSIT FINANCIAL ACCOUNT #
(BRANCH) # INSTITUTION
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