direct debit

                                                                                                                           RATES – Direct Debit Request
1. Applicant details
Property no.                                                      New application                                     Amendment of bank details/ Amount *
Registered owners
Property location
Postal address (if different to property location)
Suburb                                                                           State                                           Postcode
Contact name
Phone                                                          A/H phone                                               Mobile
Email address

2. Payment frequency
                                                                                                                                                              st       th
  Due date                                Weekly                                  Fortnightly                          Monthly – date between 1 & 28
If payment frequency other than Due Date, please specify amount. $                                                           Date commencing
     Comments
     *If amending amount only, bank details are not required

3. Financial information
Name and Branch of
Financial Institution at   NAME OF FINANCIAL INSTITUTION:                                                                                                                       _
which your account is held
                           BRANCH NAME:                                                                                                                                         _
                                      Name of Customer/s giving the DDR
Customer’s Authority                  I/We

                                                                                                    ABN/ARBN (if applicable)
                                      authorise and request the debit User (Noosa Shire Council – User ID 405075) until further notice to debit my/our account through the Bulk
                                      Electronic Clearing System (BECS) from my/our account at the Financial Institution identified below as instructed by me/us or any other
                                      amounts as instructed or authorised to be debited in accordance with the terms and conditions of the Direct Debit Request Service Agreement
                                      (DDRSA) as amended from time to time.


       ACCOUNT NAME ( please insert your name in full )                                                BSB number                              Account Number

                                                                                                 -  
                              CREDIT CARDS ARE NOT ACCEPTED FOR DIRECT DEBIT REQUESTS
                                                 If joint account all signatures may be required.

Signature                                                                       Signature

Date                                                                            Date
    * NOTE: Direct Debiting through BECS is not available on all accounts. Check with your Financial Institution before completing DDR
      By signing this form I/we acknowledge that this Direct Debit arrangement is governed by the terms of Authorisation of the DDRSA
                                                           attached to this request.

OFFICE USE ONLY - Notate prop Change notice code Create DD Confirmation letter Details Entered:


Privacy
Noosa Shire Council will only use the personal information collected for the intended purpose, to remain in contact with you regarding your request and the
legitimate functions and services of Council affecting your property. Council is authorised to collect this information in accordance with the Local Government
Act 2009 and associated laws. Access to your personal information will only be provided to appropriate Council employees and authorised officers. Your
personal information will only be disclosed to third parties with your consent, or if required to do so by law. Your personal information is handled in accordance
with Council’s Privacy Policy.




NOOSA COUNCIL                                   PO Box 141                             P. (07) 5329 6500                        [email protected]
ABN 97 969 214 121                              TEWANTIN QLD 4565                      F. (07) 5329 6501                        www.noosa.qld.gov.au