2012-2013 - Direct Debit Application Form

DIRECT DEBIT
REQUEST
ABN 20 903762 572
RATES ENQUIRIES
Telephone: 8203 7242
Email: [email protected]
Request and Authority to debit the account nominated below to pay:
CORPORATION OF THE CITY OF ADELAIDE
Request and Authority to Debit
This debtor charge will be made through the Bulk Electronic Clearing System (BECS) from your account
held at the financial institution you have nominated below and will be subject to the terms and conditions
of the Direct Debit Request Service Agreement.
Surname/Company Name
Given Names/ABN
I
request and
authorise the CORPORATION OF THE CITY OF ADELAIDE (User ID 440688) to arrange through its own
financial institution, a debit to the account I have nominated any amount the CORPORATION OF THE CITY
OF ADELAIDE has deemed payable by me.
Applicant Details
Assessment Number *
Who is Applying? *
Owner
Other
Specify Other
Contact Phone Number *
Email Address *
Property Address *
Debit Account Nomination
I nominate the following account to be debited
Financial Institution Name
_
Address
_
_
Account Name
_
--
BSB Number (Must be six digits)
Account Number
Payment Details
Please select one of the options below (Quarterly amounts will be debited the Friday before falling due)
Annually
Amount as per Rates Notice
Quarterly
Amount as per Rates Notice
Instalment due dates as per Rates Notice
Monthly
$
Last Friday of each Month
Payment Start Date
Please indicate the date you wish debits to begin
D
D
/
M
M
/
Y
Y
By signing and providing us with a valid instruction in respect to your Direct Debit Request, you have
understood and agreed to the terms and conditions governing the debit arrangements between you and
the Corporation of the City of Adelaide as set out in this Request and in your Direct Debit Request Service
Agreement.
Signed
Print Name
Date
/
/
Signed
Print Name
Date
/
/
This is your Direct Debit Service Agreement with the Corporation of the City of Adelaide, 440688 & 20 903 762 572. It explains what your
obligations are when undertaking a Direct Debit arrangement with us. It also details what our obligations are to you as your Direct Debit provider.
Please keep the copy of the agreement for future reference. It forms part of the terms and conditions of your Direct Debit Request (DDR) and should
be read in conjunction with your DDR authorisation.
Definitions
4.2
account means the account held at your financial institution from
which we are authorised to arrange for funds to be debited.
agreement means this Direct Debit Request Service Agreement
between you and us.
banking day means a day other than a Saturday or a Sunday or a
public holiday listed throughout Australia.
If there are insufficient clear funds in your account to meet a
debit payment:
(a)
you may be charged a fee and/or interest by your
financial institution;
(b)
you may also incur fees or charges imposed or
incurred by us; and
(c)
you must arrange for the 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.
debit day means the day that payment by you to us is due.
debit payment means a particular transaction where a debit is made.
direct debit request means the Direct Debit Request between us and 4.3
you.
You should check your account statement to verify that the
amounts debited from your account are correct
us or we means the Corporation of the City of Adelaide, (the Debit
User) you have authorised by requesting a Direct Debit Request.
5
Dispute 5.1
If you believe that there has been an error in debiting your
account, you should notify us directly on 8203 7203 and
confirm that notice in writing with us as soon as possible so
that we can resolve your query more quickly. Alternatively
you can take it up directly with your financial institution.
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.
you means the customer who has signed or authorised by other
means the Direct Debit Request.
your financial institution means the financial institution nominated
by you on the DDR at which the account is maintained.
1.
Debiting your account
1.1
By signing a Direct Debit Request or by providing us with a valid
instruction, 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. 5.3
1.2
We will only arrange for funds to be debited from your account as
authorised in the Direct Debit Request.
or
6.
We will only arrange for funds to be debited from your account if we
have sent to the address nominated by you in the Direct Debit
Request, a billing advice which specifies the amount payable by you
to us and when it is due.
1.3
Amendments 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 fourteen (14) days written notice.
3.
Amendments by you
3.1
You may change*, stop or defer a debit payment, or terminate this
agreement by providing us with at least fourteen (14 days)
notification by writing to:
7.
arranging it through your own financial institution, which is required to
act promptly on your instructions.
*Note: in relation to the above reference to ‘change’, your financial institution
may ‘change’ your debit payment only to the extent of advising us the
Corporation of the City of Adelaide your new account details,
4.
Your obligations
4.1
It is your responsibility to ensure that there are sufficient clear funds
available in your account to allow a debit payment to be made in
accordance with the Direct Debit Request.
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.
Confidentiality 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 that 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)
by telephoning us on 8203 7203 during business hours;
Or
(a)
7.1
Rates and Valuation Services
Adelaide City Council
GPO Box 2252
ADELAIDE SA 5001
Or
Accounts You should check:
If the debit day falls on a day that is not a banking day, we may direct
your financial institution to debit your account on the following
banking day. If you are unsure about which day your account has or
will be debited you should ask your financial institution.
2.
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 in writing.
to the extent specifically required by law; or
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 :
Rates and Valuation Services
Adelaide City Council
GPO Box 2252
ADELAIDE SA 5001
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 on the third
banking day after posting.