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Changes Form for Pre-Authorized Payment Plans

  1. For Office Use Only

  2. For TIP only

  3. Information

  4. Property Ownership

  5. Please choose one of the following

  6. Changes in Banking Information

    Please choose applicable payment plan(s)

  7. I wish to change my banking information for the above selected pre-authorized payment plan(s) at the above address and have provided 10 days notice as required.

  8. Please attach void cheque with new banking information below.

  9. Please attach void cheque with new banking information.

  10. Cancellation of Pre-Authorized Payment Plans

    Please choose applicable

  11. Please be advised that I wish to be removed from the above selected pre-authorized payment plan(s) at the above address for the following reason.

  12. I do not want payment taken from my account and have provided 10 days notice as requested.

  13. Please note that utilities payments are processed only on the due dates in February, April, June, August, October and December. If you are removed from the payment plan prior to these dates you will have to make payment another way.

  14. Changes in Tax Withdrawal Amount

    To be authorized and completed by Tax Clerk only.

  15. Section 3 - Signature & Date

  16. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  17. The personal information requested on this form is being collected under the authority of the Freedom of Information and Protection of Privacy (FOIP) Act, Section 33 (c). The information collected will be used to activate and process pre-authorized charges. If you have any questions about the collection or use of your personal information, contact the City of Beaumont’s FOIP Coordinator at 5600-49 Street, Beaumont, Alberta, T4X 1A1 or 780-929-8782.

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  19. This field is not part of the form submission.