Capital One Canada - Pre

1. Please complete all sections in order to instruct your financial institution to make payments directly from your account.
2. Please read the Authorization Terms and sign this document.
3. Please continue to make your Capital One MasterCard payments as usual until notified by us that your payment option is
set up.
4. Return the completed form with a blank personal cheque marked “VOID” to Capital One at the address below:
Capital One
P.O. Box 515, Scarborough Stn. D
Scarborough, ON M1R5N4
5. Once your payment option is set up, to change your participation in the program, or if you have any questions, please call
us at 1-800-481-3239. We will answer your questions and send you a form on which you may indicate your desired
changes. You may also notify us of changes by writing directly to our address above. Payment options may be changed or
stopped by notifying us in writing. Please allow 4 to 6 weeks for any changes requested to take effect.
ACCOUNT-OWNER INFORMATION (Please type or print clearly.)
Capital One MasterCard Number:
I wish to pay (check preferred option):
‫ ٱ‬Minimum Amount Due (as indicated on my statement)
‫ ٱ‬Total New Balance (as indicated on my statement)
‫ ٱ‬Fixed Amount $ _______._____
Branch Number
Name of Financial Institution:
Institution #
Account Number
Branch Address:
Postal Code:
Please read Authorization Terms.
Tape VOIDED Personal Cheque Here
Authorization Terms
In this Authorization, “I”, “me” and “my” refers to each Account Owner indicated on the attached.
I agree to participate in the pre-authorized debit payment plan of Capital One Bank (Canada Branch) (“Capital One”) and
authorize Capital One or its successors, assigns and agents acting on its behalf to debit from the account I have specified
(my “Account”) with the financial institution I have specified (the “Financial Institution”) on the payment due date set
out on my monthly account statement (the “Payment Due Date”) the amount that corresponds to the payment option I
have selected with respect to the Capital One MasterCard I have specified. Each debit is referred to as a “PAD”.
This Authorization is provided for the benefit of Capital One and my Financial Institution and is provided in consideration
of my Financial Institution agreeing to process debits against my Account in accordance with the rules of the Canadian
Payments Association. I understand that my Financial Institution is not responsible for validating debits made pursuant to
this Authorization.
This Authorization will terminate if any two PADs are returned to Capital One because I have insufficient funds in my
Account. I may be charged a dishonoured payment fee for each returned PAD on my Capital One MasterCard in
accordance with my Customer Agreement.
I agree that delivery of this Authorization to Capital One constitutes delivery by me to my Financial Institution. I agree
that Capital One may deliver this Authorization to its financial institution and agree to the disclosure of my personal
information contained in this Authorization to such financial institution for the purposes of processing PADS.
I understand that if I have selected either the minimum amount due or total new balance payment option, the amount of the
PAD may vary from month to month, and I will receive written notice from Capital One of the amount to be debited and
the Payment Due Date of debiting for any option that I choose, at least 10 business days before the Payment Due Date,
subject to section 8 below. However, where there is a change in the amount of fixed or variable amount PADs in response
to my direct action (such as, but not limited to, a telephone instruction) requesting such change, I understand that no prenotification will be provided and I waive any right to receive pre-notification in such circumstances.
Regardless of which payment option I choose, I understand that Capital One will not debit an amount that will result in a
credit balance on my Capital One MasterCard. Accordingly, if I make an additional payment between my statement date
and my Payment Due Date, I request that the PAD debit to my Account be processed with the following modifications.
(i) for the minimum amount due option, Capital One will debit the lesser of the minimum amount due on my
statement and my current Capital One MasterCard balance as of the Payment Due Date;
(ii) for the total new balance option, Capital One will debit the lesser of the total outstanding balance on my statement
and my current Capital One MasterCard balance as of the Payment Due Date;
(iii) for fixed amounts, Capital One will debit the lesser of the fixed amount that I have specified and my total new
balance on my statement, less any amount paid on my Capital One MasterCard as of the Payment Due Date.
I understand and consent to the fact that any modifications made to the amount of a PAD in accordance with this section
will not be reflected in the monthly PAD notice.
If Capital One permits sporadic payments, from time to time, my identity will be confirmed with a pass code or secret code
that I have established with Capital One. Any use by me of such previously established password or secret code will
signify my approval and my authorization to debit such a sporadic payment from my Account to the credit of the Capital
One MasterCard I have specified.
I may cancel this Authorization at any time either by delivering a written notice of revocation to Capital One at the address
in the attached instructions section of this Authorization or by calling 1-800-481-3239, provided Capital One can confirm
my identity, within 10 business days prior to the next Payment Due Date. This Authorization applies only to the method
of payment and I agree that cancellation of this Authorization does not terminate or otherwise have any bearing on my
Customer Agreement or any other contract that exists between Capital One and me.
I certify that all information provided with respect to the Account is accurate and I agree to inform Capital One in writing,
at the address in the attached instructions section of this Authorization, of any change in the Account information provided
in this Authorization at least 10 business days prior to the next Payment Due Date. In the event of any such change, this
Authorization will continue in respect of any new account to be used for PADs.
I may dispute a PAD by providing a signed declaration to my Financial Institution confirming that the PAD was not drawn
in accordance with this Authorization, this Authorization was revoked or any pre-notification required was not received by
me and present it to my Financial Institution up to 90 calendar days after the PAD was posted to my Account. I
acknowledge that after this period, I must resolve any disputed PAD solely with Capital One and my Financial Institution
will have no liability to me.
I warrant and guarantee that the Account Owner and all persons whose signatures are required to sign on the Account have
signed the Authorization Terms.
Applicable to the Province of Quebec only: It is the express wish of the parties that this Authorization and any related
documents be drawn up and executed in English. Les parties conviennent que la présente authorization et tous les
documents s’y rattachant soient rédigés et signés en anglais.
Name of Account Owner
Name of Account Owner