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Direct Debit Request

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Applicant Details

APPLICANT DETAILS

The information you provide will enable Council to set up a Direct Debit Request to pay nominated rates and charges or sundry debts. The information is private and confidential and Council must not disclose the information to any person or body, if it is not directly related to the purpose for which the information was collected.

I want to: *

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Is the direct debit for Rates or Sundry Debtors: *

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Are you applying as an individual or Company: *

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CUSTOMER DETAILS

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Payment Details

PAYMENT DETAILS

eg. 111 Kent St Raymond Terrace

You must select one of the search results

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REQUEST AND AUTHORITY TO DEBIT

You request and authorise Port Stephens Council user id 73606 to arrange, through its own financial institution, a debit to your nominated account any amount Port Stephens Council has deemed payable by you. This debit or charge will be made through the Bulk Electronic Clearing System (BECS) from your account held at the financial institution you nominate and will be subject to the terms and conditions of the Direct Debit Request Service Agreement.

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Date:
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Name:
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Account Details

FINANCIAL INSTITUTION ACCOUNT DETAILS TO DEBIT

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Frequency of Debits

FREQUENCY OF DEBITS

Frequency of debits: * Most customers choose quarterly direct debits.

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Frequency of debits: *

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Acknowledgement

ACKNOWLEDGEMENT

By signing and/or providing us with a valid instruction in respect to your Direct Debit Request, you have understood and agreed to the terms and conditions governing the debit agreement between you and Port Stephens Council as set out in your Direct Debit Request Service Agreement.

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Eg: Director

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Signature: *

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ACKNOWLEDGEMENT

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The information contained or referred to in this application form may be corrected and updated by you, by contacting Council. The information will be saved in Council’s records management system in accordance with Council policy and relevant legislation. Council will only use the information to process your Direct Debit Request and communicate with you about Council related matters. If you have a complaint about the use of your personal information, please contact Council’s Public Officer.

YOUR PRIVACY

Port Stephens Council is committed to protecting your privacy. We take reasonable steps to comply with relevant legislation and Council policy.

Purpose: The information you provide will enable Council to process your direct debit request and communicate with you about Council related matters.

Intended recipients: The information will only be used by Council, its contractors performing functions for Council, and other agencies such as government departments that have legislation allowing them to access Council records.

Supply: Legally required.

Consequence of Non Provision: If Council does not have your current details it will be unable to process a debit from your nominated financial institution account. If Council does not know your current address, correspondence might not reach you. If Council has no telephone or email address for you it might not be able to contact you about important matters relating to your property, accounts or applications.

Storage and security: This document will be placed on the relevant file and/or saved in Council’s records management system in accordance with Council policy and relevant legislation.

Access: Please contact Council on (02) 4988 0255 to enquire how you can access information.

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