Required fields are marked with asterisks (*)

Pre-Authorized Tax Payment Plan Application Form

Before registering for a pre-authorized payment plan, please ensure the property:

has no arrears on account
is fully assessed

Registration is required by the 20th day of the month to be effective for the current month’s withdrawal.

Property Roll #: (optional)

Property Address:

Property Owner Information

Name:

Additional Owner Name: (if applicable)

Mailing Address:

Telephone Number:

Email Address:

For verification purposes, please include one void cheque or pre-authorized debit form per application.

Line of credit accounts are not accepted.

Please upload one void cheque or pre-authorized debit form per application

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Allowed extensions pdf, doc, docx, xls, xlsx, jpg, jpeg, gif, png, tif

Payment Plan Option

Please select one payment plan option:

Due Dates (end of February, April, June, and August)

Monthly (the last business day of each month)

Authorization

I/We hereby authorize the City of Sarnia to withdraw pre-authorized payments, as indicated above, from my/our bank account, for payment property taxes

Signature:

Clear

Date:

Signature:

Clear

Date:

*If more than one signature is required for your bank account, all parties must sign*