Utilities pre-authorized direct withdrawal form

Applications to enroll or cancel utility direct withdrawals must be received by the 20th of the month.

The amount on the utility invoice will be automatically withdrawn from your bank account on the date the utility invoice is due.

Completed applications must be submitted with a void cheque or pre-authorized debit form.

Personal information provided is collected by Leduc County under the authority of Section 33(c) of the Alberta Freedom of Information and Protection of Privacy Act (the FOIP Act) and we will protect it in accordance with Part 2 of that Act. We will use it to manage your account with us and contact you if necessary.

Should you require further information about collection, use and disclosure of personal information, please contact the FOIP Coordinator at 780-770-9251 or foip@leduc-county.com.

Applicant information

Applicant name *

Phone number *

Email address *

Applicant address *

Town/city *

Province *

Postal Code *

Effective date *

Property information

Account number *

Service address *

Town/city

Province

Postal Code

Financial institution information of utilities payment account

Financial institution name

Financial institution phone number

Financial institution address

Town/city

Province

Postal Code

I/we understand that:

Leduc County and its financial institution will debit my account as listed.
That this authorization may be cancelled at any time with two weeks written notice by me/us.
That any payment returned as non-sufficient funds may result in termination of the plan, and all outstanding utility charges become due and payable and subject to penalties.
In the event of a sale of the above noted property or a change in bank accounts, I/we will notify Leduc County using the change of banking form or the cancellation portion of this form at least two weeks prior to the next due date.
Any delivery of the authorization to you constitutes a delivery by me/us.
All persons whose signatures are required to sign on this bank account have signed their agreement below.
The outstanding utilities must be paid for eligibility to enrol.

Please browse and upload a void cheque or pre-authorized debit (PAD) form. *

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The maximum total size of all files in a single form submission is 1 GB.

Signature *

OFFICE USE ONLY

Verified by

Verification date

Date payments begin

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