Direct Debit

Customer Details

Full name/s*

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Email*

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Phone*

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Property address*

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Postcode*

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Assessment number*

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Date you want the direct debit to commence*

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I/we wish to make payments:*

Annually

Quarterly (25th each quarter)

Monthly (25th each month)

Fortnightly

Weekly

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Preferred payment day

MondayTuesdayWednesdayThursdayFriday

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Amount you wish to pay

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Bank Details

Account name*

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Bank*

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Branch*

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Town/City*

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Please attach confirmation of your bank account number (e.g. deposit slip, bank statement, screen shot from internet banking)

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Authorisation Code

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Reference (if you would like a reference on your statement)

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Authorisation

I/we authorise you until further notice, to debit my/our account with all amounts that Matamata-Piako District Council (‘the initiator’) the registered initiator of the above Authorisation Code, may initiate by Direct Debit.

You must tick this box to authorise Council to initiate your direct debit

I/We acknowledge and accept that the bank accepts this authority on these Terms and Conditions.

You must agree to the terms and conditions

Please tick the box:*

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Please also read our privacy policy before sending your enquiry.

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Customer Details

Bank Details

Authorisation