- Direct Debit Request Application Form

Direct Debit Request Application Form
Payments will be automatically processed from your bank account. Goulburn-Murray Water does not charge additional fees for this method of payment. Should you
require assistance to complete this form, please contact this office on 1300 553 200
1.
Select Payment Option
Please tick (√) the appropriate payment option(s) below;
Fixed Charge Account
Monthly Payments
Annual Water Rates and Charges issued in July
To pre pay or pay overdue rates on the 16th of each month.
In Full on the Due Date
On the 2% discount Due Date
By 4 Instalments
Interest charges will apply on rate arrears and on all balances
unpaid after the due date for full payment.
Fixed Monthly Payments of: $
.
a) Until account balance is $0
b) Until this date ____ / ____ / _______
c) Until I advise GMW to Stop
Variable Charges Accounts
Water Use Fees and/or Spillable Water Fees issued in
March and/or May
On the Due Date
This direct debit will remain ongoing until such time that the customer notifies Goulburn-Murray Water in writing that they wish to terminate
their direct debit arrangement.
If you have chosen to pay your account/s on the due date or by instalments, refer to your GMW account for payment amounts and due dates.
2.
Goulburn-Murray Water Account Details
Owner of Water Account:
Account No.:
Contact Telephone Number:
3.
Bank Account Details
Please check with your financial institution to ensure the account nominated will facilitate direct debiting.
Name of Financial Institution:
Branch:
Account Name:
BSB:
4.
-
Account Number:
Customers Declaration
By signing this document I acknowledge that Goulburn-Murray Water (ABN 4676 1336 846) (User ID 371557) will debit my account in
accordance to the information stated on this application until I give them further notice in writing.
Print Name:
Date:
Signature:
/
/
Goulburn-Murray Water protects your privacy by collecting and handling your personal information in accordance with the requirements of the Information Privacy Act 2000. Personal
information collected on this form will be used for the purpose of processing your payment transaction and will be destroyed upon completion. It is usually disclosed to employees
facilitating your transaction and relevant financial institutions. We may be unable to process payment if the information sought is not provided. You may gain access to and correct your
personal information. For further information please refer to our Privacy Policy at www.g-mwater.com.au or call 58263500 to obtain a copy of this policy.
Direct Debit Request Service Agreement
Definitions:
Us or We – Goulburn-Murray Water Rural Water Authority
You – the customer who signed the Direct Debit Request.
Your Financial Institution – the Financial Institution where You hold the account that You have authorised Us to debit.
Account – the account held at Your Financial Institution from which We are authorised to debit funds.
Agreement – this Direct Debit Request Service Agreement between You and Us.
Business Day – any day other than a Saturday or a Sunday or a public holiday listed in Victoria.
Non-Business Day - is any day that is not a Business Day.
Debit Day – the day that payment by You to Us is due.
Debit Payment – a particular transaction where a debit is made.
Direct Debit Request – the Direct Debit Request Application Form signed You.
1. Debiting your account
1.1 By signing a Direct Debit Request, You have authorised Us to arrange for funds to be debited from Your Account. You should refer
to the Direct Debit Request and this Agreement for the terms of the arrangement between Us and You.
1.2 We will only arrange for funds to be debited from Your Account as authorised in the Direct Debit Request.
1.3 The first drawing under this Direct Debit Agreement will occur on the 16th day of each month after the application has been received.
1.4 If drawing date falls due on a Non-Business Day, Your Account will be debited on the next Business Day thereafter.
2. Changes by us
2.1 We may vary any details of this Agreement or a Direct Debit Request at any time by giving You at least twenty-one (21) days written
notice.
3. Changes by you
3.1 Subject to sections 3.2 and 3.3, You may change the arrangements under a Direct Debit Request by contacting Us at:
Goulburn-Murray Water, 40 Casey Street, (PO Box 165), Tatura VIC 3616 Email: [email protected]
Phone: (03) 5833 5500 Fax: (03) 5833 5501
3.2 If You wish to stop or defer a Direct Debit Payment, You must notify Us in writing at least twenty-one (21) days prior to the next
Debit Day. This notice should be given to Us in the first instance.
3.3 You may also cancel Your authority for Us to debit Your account at any time by giving Us twenty-one (21) days notice in writing prior
to the next Debit Day. This notice should be given to Us in the first instance.
4. Your obligations
4.1 It is Your responsibility to ensure that there are sufficient clear funds available in Your Account to allow a Direct Debit Payment to be
made in accordance with the Direct Debit Request.
4.2 If there are insufficient clear funds in Your Account to meet a Direct Debit Payment:
You may be charged a fee and/or interest by Your Financial Institution;
(a) You may also incur fees or changes imposed or incurred by us; and
(b) You must arrange for the Direct Debit Payment to be made by another method or arrange for sufficient clear funds to
be in Your Account by an agreed time so that We can process the Debit Payment
4.3 If You have two consecutive payments dishonoured, in addition to the fees and charges payable under clause 4.2, We shall
automatically terminate Your Direct Debit Agreement and You will be required to submit a new application to continue Your direct
debit arrangement.
4.4 You should check Your Account statement to verify that the amounts debited from Your Account are correct
5. Dispute
5.1 If You believe that there has been an error in debiting Your Account, You should notify Us directly at:
Goulburn-Murray Water, 40 Casey Street, (PO Box 165), Tatura VIC 3616 Email: [email protected]
Phone: (03) 5833 5500 Fax: (03) 5833 5501
5.2 If We conclude as a result of our investigations that Your account has been incorrectly debited We will respond to Your query by
arranging for Your Financial Institution to adjust Your Account (including interest and charges) accordingly. We will also notify You in
writing of the amount by which Your Account has been adjusted.
5.3 If We conclude as a result of our investigations that Your Account has not been incorrectly debited We will respond to Your query by
providing You with reasons and any evidence for this finding.
5.4 Any queries You may have about an error made in debiting Your Account should be directed to us in the first instance so that We
can attempt to resolve the matter between Us and You. If We cannot resolve the matter You can still refer it to Your Financial
Institution which will obtain details from You of the disputed transaction and may lodge a claim on Your behalf.
6. Accounts
6.1 You should check:
(a) With Your Financial Institution whether direct debiting is available from Your Account as direct debiting is not
available on all accounts offered by financial institutions.
(b) Your account details which You have provided to Us are correct by checking them against a recent Account
statement; and
(c) with Your Financial Institution before completing the Direct Debit Request if You have any queries about how to
complete the Direct Debit Request.
7. Confidentiality
7.1 We will keep any information (including Your Account details) in Your Direct Debit Request confidential. We will make reasonable
efforts to keep any such information that we have about You secure and to ensure than any of our employees or agents who have
access to information about You do not make any unauthorised use, modification, reproduction or disclosure of that information.
7.2 We will only disclose information that We have about You:
(a) to the extent specifically required by law; or
(b) for the purposes of this Agreement (including disclosing information in connection with any query or claim)
8. Notice
8.1 If You wish to notify Us in writing about anything relating to this Agreement, You should write to:
Goulburn-Murray Water, 40 Casey Street, (PO Box 165), Tatura VIC 3616 Email: [email protected]
8.2 We will notify You by sending a notice in the ordinary post to the address You have given Us in the Direct Debit Request.
8.3 Any notice will be deemed to have been received two Business Days after it is posted.
ABN 4676 1336 846
Goulburn-Murray Water protects the privacy of its customers by providing customer information in accordance with the Victoria Information Privacy Act
2000. For further information regarding Goulburn-Murray Water’s privacy statement please refer to our website at www.g-mwater.com.au
DM # 2993886