Town Of Pelham Pre Authorized Payment Plan Application

Pre Authorized Payment Plan 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.

First Name *

Last Name *

Mailing Address *

Mailing Address Line 2

City *

State/Province/Region *

Zip/Postal Code *

Phone Number *

Country *

Email Address *

Address of Property in Pelham (if different then mailing address above)

Choose type of account for automatic withdrawal: *

Water

Tax Plan #1 (4 withdrawals done at instalment due date: last business day of Feb, Apr, Jun & Sep)

Tax Plan #2 (10 withdrawals done from January 15th to October 15th)

Tax Plan #3 (12 withdrawals done from January 15th to December 15th)

Please Enter Your Water Account Number: (if applicable)

Please Enter Your Tax Roll Number: (if applicable)

Effective Date for Withdrawl: * +

These services are for: *

Business Use

Personal Use

Financial Institiution Information *

	Bank	Address	City	Province	Postal Code	Bank Branch Number	Account Number	Transit Number
Financial Information	Bank	Address	City	Province	Postal Code	Bank Branch Number	Account Number	Transit Number

Please Upload a void cheque: