Direct Debit Authority
METERED WATER
(Commence next due date)
PROPERTY DETAILS
Billing Number
Property Address (Please list below all properties this direct debit form is to apply to)
Property Owners Names(s)
Contact Phone Number
Email
My account to be debited (acceptor)
Initiator’s authorisation code
0
0
7
0
7
9
Name of my bank
Approved
0707
05/18
Bank
Branch
Account
Suffix
From the acceptor to my bank:
I authorise you to debit my account with the amounts of direct debit instructions received from Southland District
Council (the ‘Initiator’) with the authorisation code specified on this authority and in accordance with this authority until
further notice from me.
I agree that this authority is subject to my bank's terms and conditions that relate to my account, and the terms and
conditions listed below.
Authorised signature(s)
Date
Specific conditions relating to notices and disputes
1) I agree that the Initiator must give me at least 5 days prior notice of each direct debit, including the first direct debit in a
series.
2) Changes to the amounts or dates of a series of direct debits require 10 days prior notice to me.
3) I can also agree with the Initiator to receive a same day notice for direct debits specifically requested by me.
4) All notices must be in writing, but can be delivered electronically, if I have agreed that with the Initiator.
5) I can also ask you to reverse a direct debit up to 120 days after the direct debit if:
I didn’t receive proper notice of the amount and date of the direct debit, or
I received notice but the amount or date of the direct debit is different from the amount or date on the notice.
6) If you dishonour a direct debit but the Initiator retries it within 5 business days of the original direct debit, I understand
that the Initiator doesn’t need to notify me again about that direct debit.
RATES
Weekly
Fortnightly
Monthly
(last working day)
Quarterly
(Instalment due date)
Annually
(First instalment due date)
Start date
(for weekly/fortnightly, subsequent payments will occur on the
same day of the week as the first payment date chosen)
FOR BANK USE ONLY
Date Received
Recorded by
Checked by
Bank stamp
Original Retain at Branch
Copy forward to initiator if requested
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