Pl ease complete details and return this form to: Or post to: Moreland City Council, Locked Bag 10 MORELAND VIC 3058 DIRECT DEBIT REQUEST Request and Authority to debit the account named below to pay Moreland City Council Request and Authority To Debit Your Surname or Company Name Your Given Names or ACN/ABN Request and authorise Moreland City Council, 403607, to arrange, through its own financial institution, for any amount Moreland City Council may debit or charge you to be debited through the Bulk Electronic Clearing System from an account held at the financial institution identified below and paid to the Debit User, subject to the terms and conditions of the Direct Debit Request Service Agreement (attached) Insert the name and Bank Name address of bank or financial institution at Address which account is held Name on Bank Account: Insert details of account to be debited (ie. A. Citizen) BSB number (must be six digits) Account number Acknowledgement By signing this Direct Debit Request you acknowledge having read and understood the terms and conditions governing the debit arrangements between you and Moreland City Council as set out in this Request and in your Direct Debit Request Service Agreement. Insert your signature and address Signature 1 Date (If signing for a company, sign and print full name and capacity for signing eg. Director) Signature 2 Date Phone No: (If signing for a company, sign and print full name and capacity for signing eg. Director) Address Email: Please indicate - highlight Owner or Tenant/Occupier of Property Assessment Number: ________________ (7 digits long) Property Address: __________________________________ Email: _____________________________________________ Mark with ‘x’ preferred payment method: 4 Instalment Payments 30 September, 30 November, 28 February, 31 May 10 Monthly Payments Monthly from 15 September – 15 June (or the following working day if falls on a weekend or dates as stated on your Rate Notice Please note: Direct Debit from Credit Cards is currently not available This is a continuous agreement, that can only be cancelled via written notification received by Council. To begin a Direct Debit Arrangement all you need to do is: • Have a current savings or cheque account. Direct Debit from Credit Cards is currently not available • Fill out and sign the application form nominating either the four instalment payments or ten monthly payments arrangement. • Contact your bank or financial institution to ensure that the BSB and Account number details are correct and that your nominated account allows Direct Debit. • Send your completed application form to: Moreland City Council Locked Bag 10 Moreland Vic 3058 or fax to (03) 9240 1212 or, email to Your rate payments will then be automatically debited from your account as they fall due. If you own more than one property within Moreland City Council, please ensure that you attach the rate payment advice slip for all properties OR note every address and assessment number. Definitions Account - the account held at your financial institution from which we are authorized to arrange for funds to be debited, being a Cheque or Savings Account only Agreement - this Direct Debit Request Service Agreement between you and us Banking day - a day other than a Saturday or a Sunday or a public holiday listed throughout Australia Debit day - the day that payment is due to Council Debit payment - a particular transaction where a debit is made Direct debit request - the Direct Debit Request between us and you Us or we - Moreland City Council (the Debit User) – the organisation you have authorized by signing a direct debit request You - the customer who signed the Direct Debit Request Your financial institution - the financial institution where you hold the account that you have authorised us to arrange to debit Moreland City Council Direct Debit Arrangement Moreland City Council Direct Debit system allows you to nominate a savings or cheque account from which your rates are automatically deducted. Option 1. Your four quarterly rate instalment payments are deducted from your nominated account on their due dates. Option 2. Spread your rate payments over ten monthly deductions. The ten-month period commences on the 15 September and ends on the 15 June each year. If there are arrears owing and you wish to utilise this payment method, please contact the Citizen S

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