Authority Form for Debt Repayments

Authority Form for Debt Repayments
Payer Details
Authority for automatic payments
To The Manager
(Not to operate as an assignment or agreement)
Name of Bank
This is a new authority, or
As from
/
/
(first payment date) this authority
replaces existing authorities for
$
in favour of the same payee.
Branch
Name of Account
Account Details
On behalf of (name if other than payer)
Bank/Branch/Account Number/Suffix
Details to appear on my/our Bank Statement:
Particulars
Code
Reference
Frequency and Amount
Last Payment Date
First Payment Date
OR
Frequency:
Weekly
Fixed Amount
Fortnightly
Until further notice (please tick)
Four Weekly
Monthly
Amount
Amount in Words
$
$
Complete if applicable (one option only)
Variable Last Amount Amount
Amount in Words
First
$
$
Last
(circle one)
Specify other period
Payee Details
Pay to the credit of:
Name of Bank
Branch
WESTPAC
NZ GOVERNMENT BRANCH
Name of Account
Account Details (Bank/Branch/Account Number/Suffix)
03-0049-0006243-025
WORK AND INCOME DEBTORS PAYMENT ACCOUNT
Details to appear on payee’s Bank Statement:
Surname and Initial
Client Number
D
O
Authorisation
1. Please make this automatic payment as detailed by debiting my/our account.
2. I/We understand and accept that the Bank accepts this authority only on the conditions listed over the page.
NAME OF ACCOUNT
CLIENT’S SIGNATURE
CONTACT TELEPHONE NO.
CLIENT’S SIGNATURE
CONTACT TELEPHONE NO.
DATE
ISS570 – JAN 2011
DAY
MONTH
YEAR
DAY
MONTH
YEAR
DATE
1
Conditions:
1. The Bank will use reasonable care and skill to give effect to the directions given to it in this authority.
2. Where the directions given in this authority have been given by me/us for the purpose of a business, the Bank accepts those
directions without any responsibility or liability for any refusal or omission to make all or any of the payments or for late payment or
for any omission to follow such.
3. The Bank accepts no responsibility or liability for the accuracy of the information contained in the payment information fields on this
form.
4. I/We undertake to advise the Bank immediately of any information about payments shown on bank statements which is incorrect.
5. This authority is subject to any arrangement now or hereafter subsisting between myself/ourselves and the Bank in relation to my/
our account.
6. The Bank may 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 or cheque which I/We may now or hereafter give to the Bank or draw on my/our account.
7. The Bank may in it's absolute discretion refuse to make any one or more payments pursuant to this authority where there are
insufficient funds available in my/our account.
8. This authority may be terminated or reduced by the Bank or the payee without notice to me/us in respect of the payments detailed
above.
9. This authority will remain in force and effect in respect of all payments made in good faith notwithstanding my/our death or
bankruptcy or any revocation of this authority until notice of my/our death or bankruptcy or other revocation is received by the bank.
10. All current Bank and Government charges for this service in force from time to time are to be debited to my/our account.
Bank Use
RECORDED BY
CHECKED BY
DATE RECEIVED
ISS570 – JAN 2011
DAY
MONTH
YEAR
2