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Payor's PAD Agreement

  1. Cancellation or change of information requires 10 days’ notice (Use Changes Form for Pre-Authorized Payment Plans)
  2. Section 1 - Account Information
  3. Would like to join Pre-Authorized Payment Plan for:
    Please check applicable box
  4. Section 2 - Payor Information
    Account Holder(s) Name(s) and Address(s) (the "Payor")
  5. Section 3 - Payee Information
  6. Name:
    City of Beaumont
  7. Address:
    5600 49 Street
  8. City / Town:
  9. Province:
  10. Postal Code:
    T4X 1A1
  11. Phone:
  12. Section 4 - Payment Details
  13. Utilities
    Amount of payment Variable Bi-monthly payments on due dates in February, April, June, August, October, December.
  14. Please atach one of the following.
  15. Section 5 - Authorization
  16. I/We acknowledge that this Authorization is provided for the benefit of the “Payee” and “Processing Institution” and is provided in consideration of Processing Institution agreeing to process debits (“PADs”) against the Account with Processing Institution in accordance with the Rules of the Canadian Payments Association (the “CPA Rules”). By Signing this Authorization, the Payor acknowledges having received and having read a copy of this Agreement, including the terms and conditions and acknowledges understanding of such.
  17. We warrant and guarantee that the person(s) whose signature(s) are required to sign on the Account have signed the Authorization.
  18. 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.
  19. The personal information requested on this form is being collected under the authority of the City of Beaumont Bylaw 382 and Section 33(c) of the Freedom of Information and Protection of Privacy (FOIP) Act. The information collected will be used as for the purpose of setting up utility billing.

    If you have any questions about the collection or use of your personal information, contact the City of Beaumont’s FOIP Coordinator at:
    City of Beaumont's FOIP Coordinator
    5600-49th Street
    Beaumont, AB T4X 1A1
    Phone: 780-929-8782
  20. Leave This Blank:

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