UTILITY PRE-AUTHORIZED DEBIT (PAD) AGREEMENT

I/we authorize the M.D. of Pincher Creek No. 9 (MD) and its financial institution to electronically debit my/our account in accordance with the MD's Utilities Bylaw, and for the amount to withdrawn from my/our account on the fifteen (15th) day bi-monthly or on the first business day following.

A specimen cheque for my/our account marked 'VOID' is attached to this application.

I/we acknowledge that in the event any payment is not honored, a $25.00 NSF fee will be applied, the balance will deemed outstanding and payable within 30 days.

In the event of two (2) consecutive missed payments, I/we acknowledge that my/our participation in the plan will be cancelled and all applicable penalties and fees will be applied.

This authorized debit and the PAD program participation may be cancelled upon written notice to the M.D. of Pincher Creek No. 9 by me/us not less than fourteen (14) days prior to the next payment withdrawal date. I/we may obtain a sample cancellation form, or further information on their right to cancel a PAD Agreement, at my/our financial institution or by visiting www.cdnpay.ca.

I/we will notify the M.D. of Pincher Creek No. 9 in writing of a change in bank account information within fourteen (14) days prior to the next withdrawal date.

All persons whose signatures are required on the bank account being used for this PAD application, have signed this agreement below.

By copy of this form, the owner/applicant acknowledges notification of and agrees to abide by the Terms and Conditions of the Pre-Authorized Debit services provided by the M.D. of Pincher Creek No. 9's financial institution.

I/we have certain recourse rights if any debit does not comply with this agreement. For example, I/we have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAD Agreement. To obtain more information on my/our recourse rights, I/we may contact my/our financial institution or visit www.cdnpay.ca.

Please type your name here to accept the Terms and Conditions:

This personal information is being collected under the authority of the MD of Pincher Creek No. 9 as it directly relates to and is necessary for operating a program or activity of the MD. This collection is authorized by section 4 of the Protection and Privacy Act. For questions about the collection of personal information, contact the Privacy Officer at 403-627-3130, MD Box 279, Pincher Creek, Alberta T0K 1W0 / 1037 Herron Ave / P 403-627-3130 / F 403-627-5070 / info@mdpinchercreek.ab.ca.