Electronic Funds Transfer Payment

Welcome

This information will be used to pay amounts owing by the City of Clarence-Rockland to your organization by direct deposit to the bank account you identify below. The email address provided will be used to send a remittance advice of the payement. It is advisable to use a secured generic email that will not be affected by change of staff in your organization. Notice of changed to this information or temination must be made to the City using this form. We require 15 days notice to process changes. Any duplicate payement, overpayment, fraudulent payment or payment made in error will be promptly returned to the City.

What type of application are you submitting?

Change of Direct Deposit Information

New Direct Deposit Application

Section A - Vendor Information

Vendor Name :

GST Number :

Contact Person Last Name :

Contact Person First Name :

Phone number (including area code and extension) :

Email Address (for payment notification) :

Section B - Banking Information

Branch number :

Institution number :

Account number :

Name of Financial Institution :

Branch :

Provide a photo of a void cheque or a pre-authorized debit form :

One file only.
64 MB limit.
Allowed types: pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif.

Section C - Authorization

We have the authority to direct the City of Clarence-Rockland, through its banker of record, to deposit payments to the bank account indicated above and to email the payment notification to the email listed above. We agree to the conditions set out. We will advise the City of any change to the information provided by filing another signed copy of this form.

Last name :

First name :

Phone number :

Signature :

Sign above

Date :

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Seasonal load restrictions

Electronic Funds Transfer Payment

Welcome

Section A - Vendor Information

Section B - Banking Information

Section C - Authorization