Required fields are marked with asterisks (*)

Pre-authorized payment plan change form

This form is for the cancellation of a pre-authorized payment plan or to make a change to the banking information of an existing pre-authorized payment plan.

Part A - Instructions

Step 1: Complete Parts B to D of the Pre-Authorized Payment Plan Change Form.

Step 2: Attach banking information if applicable.

An unsigned cheque marked “VOID” or
A document from your financial institution detailing your bank account information

Step 3: Submit Change Form at least 10 days prior to your invoice due date.

Part B - Account and Contact Information

Account number

Name

Telephone number

Email address

Part C - Requested Action

Please select an action

Cancellation

Change of Bank Account

Part D - Authorization

I, as the account owner or legal representative, authorize the City of Peterborough to make changes to my PAP Plan as outlined in this form.

Signature

Clear

Date of signature