Pre-Authorized Banking Payments - Water and Sewer Utility

Pre-Authorized Banking Payments - Water and Sewer Utility
I hereby authorize the City of Miramichi to charge the amount equal to the quarterly water and sewage invoice (pay on due date), for the following address. I understand that I will need to provide payment information, in person or by phone, to the city to finalize the pre-authorization.
12 Digit Water/Sewer Account Number:
Name

First NameLast Name
Property Owner (if different from above):
Service Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (If different from Service Address):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Payment Schedule

If you would like payments to be processed for an amount other than the amount due, please specify the payment amount and date(s)below:
Payment Date/Frequency:
Payment Amount:
Banking Information

Please provide the banking information for the account you'd like debited.
Bank:
Transit:
Account:
PLEASE UPDATE A COPY OF A VOID CHEQUE
Upload your void cheque here:

Cancelof
Property Owner Signature:
Should be Empty:

Payment Schedule