Rates Direct Debit Request

I/we request you, Hornsby Shire Council, User ID number 661297, to arrange for my/our rates to be debited from my/our nominated account at the financial institution shown below according to the schedule specified below, until further notice in writing.

Details of the property for which rates are to be direct debited: (details can be found on the rate notice)

Property Reference Number *

Property Owner's Name/s *

Property Address *

Postcode *

Daytime Phone Number *

Email Address *

Details of the person who is going to have their bank account debited

Account Holder's Name *

Account Holder's Address *

Details of the account to be debited. (Note: Direct debiting is not available from any credit card)

Name of Financial Institution *

Branch *

BSB Number *

Account Number *

Payment Schedule Preference

Please select your preferred payment schedule: *

Quarterly

To commence from: *

1st2nd3rd4th

Rates instalment due dates are 31 August, 30 November, 28 February, 31 May.

Schedule *

WeeklyFortnightlyMonthly

Council will recalculate your payment amount annually to ensure your rates are paid by the end of the financial year.

Schedule Start Date *

Declaration

I am the account holder or the authorised person for the company for the nominated bank account.

*

I authorise for this Direct Debit to be actioned by Councils service provider (Payble). *

I have read and understand the Direct Debit Service Agreement. *

Account Holder's Signature *

Draw signature|Type signatureClear

Date *

Account Holder's Signature (If joint account)

Draw signature|Type signatureClear

Date

You will still receive your Annual Rate Notice every year. If you elect to pay by instalment quarterly, a notice will be issued showing the amount being deducted.

Please return the Direct Debit Request Form at least 2 weeks prior to the due date.

Upon submitting, you will be emailed a copy of this form, please keep a copy for your records.

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