Pre-Authorized Payment Plan Account Number(Required) Customer Name(Required) First Last Service Address(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone(Required)Email(Required) Payment Options(Required) Pre-Authorized Chequing (1) Equal Payment Through Pre-Authorized Chequing (2) The account balance will be withdrawn from your designated bank account on the date indicated on each billing statement.Amount of monthly budget payment, to be determined Wasaga Distribution, will be withdrawn from your designated bank account, followed by an account reconciliation payment/credit in the 12th month of the program. To ensure the plan is consistent with customer usage, Wasaga Distribution conducts a mid-year review to ensure that the monthly payment amount accurately reflects each participating customer’s consumption patterns and charges. If there is a significant difference Wasaga Distribution notifies customers if a change to their monthly payment amount is required. Monthly Equal Payment Date:(Required) 1st of the Month 15th of the Month Attach a “void” cheque with your application. Your account balance must be at a zero balance before commencing with either Plan. Once on the Plan, you will continue to receive Wasaga Distribution bills as usual. This authority is to remain in effect until Wasaga Distribution has receive written notification of its change or termination. This notification must be received at least ten (10) business days before the next debit is scheduled at the address provided above. Upon termination, ANY AMOUNT DUE shall be paid directly to Wasaga Distribution. Cancellation of pre-authorized debit does not constitute cancelation of service by Wasaga Distribution and the customer shall be liable for any past, present or future amounts owing. Void Cheque(Required)Max. file size: 64 MB.Please upload a picture or scanned void cheque.Account Payment Agreement I agreeI/We hear by authorize Wasaga Distribution to debit my bank/trust account for payments due. I/We acknowledge that insufficient funds may result in service charges as applicable and removal after two occurrences. I/We undertake to ensure sufficient funds will be available each month to cover the undersigned to Wasaga Distribution in payment of my/our monthly billed services.
