PRE-AUTHORIZED DEBIT FORM A copy of a void cheque or

Mail / Fax to: R.M. of Brokenhead
ATT: Tax Department
P.O. Box 490
Beausejour, Manitoba
R0E 0C0
Phone: 204-268-6700
Fax:
204-268-1504
E-mail: [email protected]
Be sure to include:
- Void Cheque or Deposit Slip
PRE-AUTHORIZED DEBIT FORM
Customer Information:
Name:
Mailing Address:
City:
Province:
Home Phone: (
)
Postal Code:
Business Phone: (
)
Email:
Tax Roll Account #
Payments are to be debited from the following account:
Financial Institution Name:
Financial Institution Address:
City:
Phone: (
Province:
Postal Code:
)
Banking Information:
Bank ID
Transit No
Authorization
Bank Account No
PAYMENT DATE PREFFERENCE: 5th of the month or 20th of the month
I/We hereby request and authorize TelPay Incorporated (Payment Processor) on behalf of the Rural Municipality of
Brokenhead to debit payments and service charges authorized by me/us from the chequing account specified by me. Notice
of cancellation of this authorization may be made by me/us at any time. Such notice shall not have effect on debits made
prior to cancellation.
** NOTE: If funds are not available, a NSF charge of $30.00 will be applied.
Customer Name: _______________________ _
Customer Name: ______________________________
Signature: _______________________________
Signature: ___________________________________
Date: ___________________________________
Date: _______________________________________
** The Rural Municipality of Brokenhead warrants that it will maintain the Company’s information confidential
and will use it exclusively for the purposes of affecting the payment services of TelPay.
A copy of a void cheque or deposit slip is required to process this form.
June 9/11