<form-template> <fields> <field type="header" subtype="h1" label="Schedule &quot;B&quot;" class="header"></field> <field type="header" subtype="h1" label="AUTHORIZATION FOR CONSUMER PRE-AUTHORIZED DEBIT PLAN" class="header"></field> <field type="header" subtype="h1" label="Authorization of the Payor to the Payee to Direct Debit an Account" class="header"></field> <field type="paragraph" subtype="p" label="Instructions:" class="paragraph"></field> <field type="paragraph" subtype="p" label="1. Please read and accept the Terms &amp; Conditions below." class="paragraph"></field> <field type="header" subtype="h3" label="AUTHORIZATION FOR CONSUMER PRE-AUTHORIZED DEBIT PLAN " class="header"></field> <field type="header" subtype="h3" label="Terms &amp; Conditions " class="header"></field> <field type="paragraph" subtype="p" label="1. In this Authorization, &quot;I&quot;, &quot;me&quot; and &quot;my&quot; refers to each Account Holder who signs below." class="paragraph"></field> <field type="paragraph" subtype="p" label="2. I agree to participate in this Pre-Authorized Debit Plan for personal/household or consumer purposes and I authorize the Payee indicated on the reverse hereof and any successor or assign of the Payee to draw a debit in paper, electronic or other form for the purpose of making payment for consumer goods or services (a &quot;Consumer PAD&quot;), on my account indicated on the reverse hereof (the &quot;Account&quot;) at the financial institution indicated on the reverse-hereof (the &quot;Financial Institution&quot;) and I authorize the Financial Institution to honour and pay such debits. This Authorization is provided for the benefit of the Payee and my Financial Institution and is provided in consideration of my Financial Institution agreeing to provide debits against my Account in accordance with the Rules of the Canadian Payments Association. I agree that any direction I may provide to draw a Consumer PAD, and any Consumer -PAD drawn in accordance with this Authorization, shall be binding on me as if signed by me, and, in the case of paper debits, as if they were cheques signed by me." class="paragraph"></field> <field type="paragraph" subtype="p" label="3. I may revoke this Authorization at any time by delivering a written notice of revocation to the Payee. This Authorization applies only to the method of payment and I agree that revocation of this Authorization does not terminate or otherwise have any bearing on any contract that exists between me and the Payee." class="paragraph"></field> <field type="paragraph" subtype="p" label="4. I agree that my Financial Institution is not required to verify that any Consumer PAD has been drawn in accordance with this Authorization, including the amount, frequency and fulfilment of any purpose of any Consumer PAD." class="paragraph"></field> <field type="paragraph" subtype="p" label="5. I agree that delivery of this Authorization to the Payee constitutes delivery by me to my Financial Institution. I agree that the Payee may deliver this Authorization to the Payee's financial institution and agree to the disclosure of any personal information which may be contained in this Authorization to such financial institution." class="paragraph"></field> <field type="paragraph" subtype="p" label="6. (a) I understand that with respect to:" class="paragraph"></field> <field type="paragraph" subtype="p" label="(i) fixed amount Consumer PADs, we shall receive written notice from the Payee of the amount to be debited and the due date(s) of debiting, at least ten (10) calendar days before the due date of the first Consumer PAD, and such notice shall be received every time there is a change in the amount or payment date(s); (ii) variable amount Consumer PADs, we shall receive written notice from the Payee of the amount to be debited and the due date(s) of debiting, at least ten (10) calendar days before the due date of every Consumer PAD; and (iii) a Consumer PAD Plan that provides for the issuance of a Consumer PAD in response to my direct action (such-as, but not limited to, a telephone instruction) requesting the Payee to issue a Consumer PAD in full or partial payment of a billing received by us, the ten (10) day pre-notification is waived. " class="paragraph"></field> <field type="paragraph" subtype="p" label="7. I may dispute a Consumer PAD by providing a signed declaration to my Financial Institution under the following conditions" class="paragraph"></field> <field type="paragraph" subtype="p" label="(a) the Consumer PAD was not drawn in accordance with this Authorization; (b) this Authorization was revoked; (c) any pre-notification required by section 6 was not received by me; " class="paragraph"></field> <field type="paragraph" subtype="p" label="I acknowledge that in order to obtain reimbursement from my Financial Institution for the amount of a disputed Consumer PAD, I must sign a declaration to the effect that either (a), (b) or (c) above took place and present it to my Financial Institution up to and including but not later than ninety (90) calendar days after the date on which the disputed Consumer PAD was posted to the Account. I acknowledge that, after this ninety (90) day period, I shall resolve any dispute regarding a Consumer PAD solely with the Payee, and that my Financial Institution shall have no liability to me respecting any such disputed Consumer PAD." class="paragraph"></field> <field type="paragraph" subtype="p" label="8. I certify that all information provided with respect to the Account is accurate and I agree to inform the Payee, in writing, of any change in the Account information provided in this Authorization at least ten (10) business days prior to the next due date of a Consumer PAD. In the event of any such change, this Authorization shall continue in respect of any new account to be used for Consumer PADs." class="paragraph"></field> <field type="paragraph" subtype="p" label="9. I warrant and guarantee that all persons whose signatures are required to sign on the Account have signed this Authorization below." class="paragraph"></field> <field type="paragraph" subtype="p" label="10 I understand and agree to the foregoing terms and conditions." class="paragraph"></field> <field type="paragraph" subtype="p" label="11. I agree to comply with the Rules of the Canadian Payments Association or any other rules or regulations which may affect the services described herein, as may be introduced in the future or are currently in effect and I agree to execute any further documentation which may be prescribed from time to time by the Canadian Payments Association in respect of the services described herein." class="paragraph"></field> <field type="paragraph" subtype="p" label="12. Applicable to the Province of Quebec only: It is the express wish of the parties that this Authorization and any related documents be drawn up and executed in English. Les parties conviennent que la présente autorisation et tous les documents s'y rattachant soient rédigés et signés en anglais." class="paragraph"></field> <field type="checkbox" required="true" label="I accept the terms and conditions as listed above" class="checkbox" name="checkbox-1587391724277"></field> <field type="paragraph" subtype="p" label=" 2. Please complete all the following sections in order to instruct your financial institution to make payments directly from your account." class="paragraph"></field> <field type="paragraph" subtype="p" label="3. Please attach a blank cheque marked &quot;VOID&quot;. Select 'Choose File&quot; to attach the document (a picture of the VOID Cheque is acceptable). " class="paragraph"></field> <field type="file" required="true" class="form-control file-input" name="file-1587393063711"></field> <field type="paragraph" subtype="p" label=" 4. If you have any questions, please call the Payee (204-857-3821). " class="paragraph"></field> <field type="checkbox-group" required="true" label="I would like to set up Pre-Authorized Debit for:" class="checkbox-group" name="checkbox-group-1587477174107"> <option value="option-1" selected="true">Taxes </option> <option value="option-2">Water Bill</option> </field> <field type="text" subtype="text" required="true" label="Account/Roll Number:" class="form-control text-input" name="text-1587477281880"></field> <field type="paragraph" subtype="p" label="PAYOR INFORMATION " class="paragraph"></field> <field type="text" subtype="text" required="true" label="Payor Name(s):" class="form-control text-input" name="text-1587392169867"></field> <field type="text" subtype="text" required="true" label="Address:" class="form-control text-input" name="text-1587392200792"></field> <field type="text" subtype="text" label="Email Address:" class="form-control text-input" name="text-1587477425258"></field> <field type="text" subtype="text" required="true" label="Telephone:" class="form-control text-input" name="text-1587392219916"></field> <field type="text" subtype="text" required="true" label="Signature of Payor(s): Please type names" class="form-control text-input" name="text-1587392328717"></field> <field type="date" required="true" label="Date Field" class="form-control calendar" name="date-1587392351563"></field> <field type="paragraph" subtype="p" label="PAYOR FINANCIAL INSTITUTION/BANKING INFORMATION" class="paragraph"></field> <field type="text" subtype="text" required="true" label="Branch Number (5 digits)" class="form-control text-input" name="text-1587392398574"></field> <field type="text" subtype="text" required="true" label="Institution Number (3 digits)" class="form-control text-input" name="text-1587392434381"></field> <field type="text" subtype="text" required="true" label="Account Number (12 digits)" class="form-control text-input" name="text-1587392466067"></field> <field type="text" subtype="text" required="true" label="Name of Financial Institution" class="form-control text-input" name="text-1587392506971"></field> <field type="text" subtype="text" required="true" label="Branch" class="form-control text-input" name="text-1587392547715"></field> <field type="text" subtype="text" required="true" label="Branch Address" class="form-control text-input" name="text-1587392560300"></field> <field type="text" subtype="text" required="true" label="City/Province" class="form-control text-input" name="text-1587392574060"></field> <field type="text" subtype="text" required="true" label="Postal Code" class="form-control text-input" name="text-1587392593074"></field> <field type="paragraph" subtype="p" label="PAYEE INFORMATION" class="paragraph"></field> <field type="paragraph" subtype="p" label="Rural Municipality of Portage la Prairie" class="paragraph"></field> <field type="paragraph" subtype="p" label="35 Tupper Street South" class="paragraph"></field> <field type="paragraph" subtype="p" label="Portage la Prairie, MB R1N 1W7" class="paragraph"></field> </fields> </form-template> Submit Submitting...
