Pre Authorized Debit Cancellation Form

Pre-Authorized Debit Cancellation Notice Form

The Corporation of the Town of Pelham
20 Pelham Town Square. Fonthill, ON L0S 1E0 Tel. (905) 892-2607 Fax (905) 892-5055

Please use this form to update your information, thus ensuring our records are accurate.

To (Payee Name): *

Date(today): * +

I/We (Payor Name): *

Wish to cancel my/our authorization to issue (Personal, Business, Funds Transfer or Cash Management): *

Pre authorized debits in the amount of: *

against my/our account number: *

Effective on Date: * +

I/We acknowledge that this cancellation does not terminate any other obligation that I/we may have with the Payee. *

Yes