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Pre-Authorized Payment Plan Form

Terms and Conditions

I(we) authorize the Township of Scugog to debit the account as indicated on the attached “VOID” cheque or a Pre Authorized Debit Form from your Financial Institution under the terms and conditions agreed by me(us) with the Township of Scugog until such time as written notification to the contrary or submission of a cancellation form is given.  I(we) will check my(our) statement regularly to confirm that withdrawals are being made in accordance with the authorization. I(we) warrant that all person(s) signature(s) are required to sign on this account have signed this agreement.

I(we) acknowledge that delivery of authorization to the Township of Scugog constitutes delivery by me(us) to the branch of the financial institution at which I(we) maintain an account at and that such financial institution is not required to verify that the payment(s) are withdrawn in accordance with this authorization.

I(we) will notify the Township of Scugog in writing, a minimum of fourteen(14) days prior to the next due date of the pre-authorized debit of any changes in the account information or for termination of this authorization. I(we) acknowledge that if notice is not given to cancel the plan when a sale occurs any payments withdrawn after the sale date will remain on the account and it will be the vendor’s responsibility to negotiate these payments with their lawyers.

I(we) acknowledge that we can be terminated from this plan after two(2) payments have been returned by my(our) bank OR if no replacement cheque is received after the first returned payment and that administrative and interest charges will apply. If any of my(our) pre-authorized payments do not clear through my(our) bank account the Township will charge me(us) an administrative fee. If returned payments are not replaced on time, I (we) can also be removed from the Pre-Authorized Payment Plan and returned to the regular instalment plan. I(we) may apply for cancellation of the plan by visiting

I(we) have recourse rights if any debit does not comply with this agreement.  I (we) have rights to receive reimbursement for any PAP that is not authorized or is not consistent with this PAP agreement. To obtain a form for a Reimbursement Claim or for more information on my/our recourse rights, I(we) may contact my/our financial institution or visit

Note: Personal information on this form is being collected under the authority of the Municipal Freedom of Information and Protection of Privacy Act R.S.O. c. F.31, s.39(2). Questions about the collection of personal information may be directed to the Township of Scugog, 181 Perry Street, P.O. Box 780, Port Perry ON, L9L 1A7, or at (905) 985-7346.


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By checking this box I (we) acknowledge that we have read and understand the terms and conditions of this plan:

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