Direct Debit Form

I/We request Forbes Shire Council (Debit ID No: 126154) to arrange for funds to be debited from my/our nominated account at the financial institution shown below:-

Applicants Details

Name:* - required

Postal address:* - required

Telephone:* - required

Email:* - required

Amendment to a previous Direct Debit ?* - required

Yes No

Financial Institution Details

Financial institution name:* - required

Branch:* - required

Name the account is held:* - required

BSB:* - required

Account number:* - required

Commencing Date

(Payment will be deducted on corresponding Thursday)

On the following basis:

Assessment or debtor no:

Property address or FSC debtor name:

Frequency* - required

Weekly Fortnightly Monthly

Amount RATES:

Amount DEBTOR:

Amount WATER:

For the amount stated on the rates notice issued by Council on the following basis:

Assessment:

Property address:

RATES:* - required

Annually Instalment

WATER:* - required

Pay in Full

For the total amount due on the Tax Invoice issued by Council for:

FSC Debtor Number:

FSC Debtor Name:

I agree to the terms and conditions in Forbes Shire Councils Direct Debit Service Agreement.* - required

Signature* - required

Please type your signature

Please sign here

Date* - required

(If debiting from a joint bank account, all signatures are required.)

Please complete if nominating authority to debit above mentioned account for more than one property:

Assessment # 2

Assessment Number:

Frequency (select from dropdown)

Rates:

Water:

Assessment Number:

Frequency (select from dropdown)

Rates:

Water:

Assessment # 3

Assessment Number:

Frequency (select from dropdown)

Rates:

Water:

Mandatory field(s) marked with *