I hereby authorize the Township of Ashfield-Colborne-Wawanosh and the financial institution indicated on my VOID cheque/application to begin withdrawals for payment of my tax account(s). This authority is to remain in effect until I notify the Township of its termination.

Name: ____________________________________________________

Address: ____________________________________________________

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Phone: Home:____________________Work:_____________________

Signature:_____________________________________________________

Starting Date:_______________________________________________

Payment Type: Installment Date Only

Property Roll Number(s):

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Attach VOID cheque/deposit slip.