Account Details:
Bank Branch Number
0308442
TO: The Mana
g
er: Please
p
rint full
p
ostal address clearl
y
Bank
Branch
Address
Date
/ / YYYY
I/We authorise
y
ou until further notice in writin
g
to debit m
y
/our account with
y
ou all amounts which -
(hereinafter referred to as the Initiator)
The re
g
istered Initiator of the above Authorisation Code, ma
y
initiate b
y
Direct Debit.
I/We acknowled
g
e and acce
p
t that the bank acce
p
ts this authorit
y
onl
y
u
p
on the conditions listed on the reverse of this form.
FOR BANK USE ONLY
Ori
g
inal - Retain at Branch
Co
py
- Forward to Initiator if re
q
uested
Version 30 July 2013
INFORMATION TO APPEAR ON MY/OUR BANK STATEMENT
ACCOUNT INFORMATION
Name of Account to be
debited:
AUTHORITY TO ACCEPT
DIRECT DEBITS
(not to operate as an assignment or agreement)
Account Number Suffix
Authorisation Code
DD MM
Gore District Council
Payer Particulars Payer Code
Payer Reference
Name of Account (Customer to complete)
Authorised Signatures
SIGNATURE SIGNATURE
APPROVED
BANK
STAMP
Date Received Recorded By Checked By
0844
05 16
Weekly Fortnightly
I/We wishtomakepayments: Monthly Instalment
Datepaymentsaretocommencefrom:
AssessmentNumber/s
RATESDIRECTDEBIT
Tobereturnedto:
29BowlerAvenue,POBox8,GORE9740
Phone(03)2090330
ContactName:
Phone:
Mobile:
Email:
Thisreplacesapreviousdirectdebitauthority(tick)
Icurrently receivearatesrebate(tick)
1.
The Initiator:
(a)
communicate electronically).
(b)
terminate this Authority as to future payments by notice in writing to me/us.
(c) May, upon receiving written notice (dated after the date of this authority) from a bank to which I/we have
transferred my/our bank account, initiate Direct Debits in reliance of that written notice and this Authority
from the account identified in the written notice.
2.
The Custome
r
ma
y
:
(a)
(b)
3.
The Custome
r
acknowled
g
es that:
(a) This Authority will remain in full force and effect in respect of all Direct Debits passed to my/our account in
(b)
(c)
(d)
- the accuracy of information about Direct Debits on Bank statements
- any variations between notices given by the Initiator and the amounts of Direct Debits
(e)
In any such situation the dispute lies between me/us and the initiator.
4.
The Bank ma
y
:
(a)
(b)
(c)
Version 30 July 2013
At any time, terminate this Authority as to future payments by giving notice of termination to the Bank and to
CONDITIONS OF THIS AUTHORITY TO ACCEPT DIRECT DEBITS
Has agreed to give advance notice of the net amount of each Direct Debit and the due date of the debiting
at least 10 calendar days (but not more than 2 calendar months) before the date when the Direct Debit will
be initiated. This notice will be provided in writing (including by electronic means and SMS where the
Customer has provided prior written consent (including by electronic means including SMS) to
The advance notice will include the following message:-
“Unless advice to the contrary is received from you by (date*), the amount of $………, will be directly debited
to your account on (initiating date).”
* This date will be at least two (2) days prior to the initiating date to allow for amendment of Direct Debits.
May, upon the relationship which gave rise to this Authority being terminated, give notice to the Bank that no
further Direct Debits are to be initiated under the authority. Upon reciept of such notice the Bank may
accepts no responsibility or liability in respect of:
the Initiator by the means agreed by the customer, Bank and Initiator.
Stop payment of any Direct Debit to be initiated under this authority by the Initiator by giving written notice to
the Bank prior to the Direct Debit being paid by the Bank.
good faith notwithstanding my/our death, bankruptcy or other revocation of this authority until actual notice
of such event is received by the Bank.
In any event this authority is subject to any arrangement now or hereafter existing between me/us and the
Bank in relation to my/our account.
Any dispute as to the correctness or validity of an amount debited to my/our account shall not be the
concern of the Bank except in so far as the Direct Debit has not been paid in accordance with this authority.
Any other disputes lies between me/us and the Initiator.
Where the Bank has used reasonable care and skill in acting in accordance with this authority, the Bank
* These terms and conditions are PNZ approved and are non-negotiable.
The Bank is not responsible for, or under any liability in respect of the Initiator’s failure to give notice in
accordance with 1(a) nor for the non-receipt or late receipt of notice by me/us for any reason whatsoever.
In it's absolute discretion conclusively determine the order of priority of payment by it of any monies pursuant to
this or any other authority, cheque or draft properly signed by me/us and given to or drawn on the Bank.
At any time terminate this authority as to future payments by notice in writing to me/us.
Charge its current fees for this service in force from time-to-time.
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