Pre-Authorized Payment Application

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.

Your Name (required):

Your Email (required):

Your Address (required):

Home Telephone:
Work/Mobile Telephone:

Starting Date:

Payment Type: Installment Date Only

Property Roll Number(s):

Attach a VOID cheque/deposit slip image/scan.

For security purposes, please answer the following simple math problem: What is four plus three? 4+3=?