2. 

3. Utilities 
   Pre-Authorized Payment Plan (UPP) 
   Application

5. The Town of Diamond Valley offers the Utilities Pre-Authorized Payment Plan (UPP) to help simplify the bill-paying process by authorizing automatic bi-monthly deductions from your chequing account. Enjoy the convenience and peace of mind knowing that your payments are handled seamlessly every two months.

7. ACCOUNT HOLDER INFORMATION
9. Request Type*

   1. New utility account holder
   2. Existing utility account holder
12. Requested Start Date*
    Requested Start Date

    Enrolment requests must be received no later than the 10th day of the month in order to be processed for inclusion in the next cycle's payments. Payments are withdrawn on the 15th day of each month, or the next business day.

13. Account or Roll Number

    (If unknown, please leave blank)

15. First Name*
16. Last Name*
18. Owner or Renter?*

    1. Owner
    2. Renter
20. If renting, name of registered property owner(s)
22. Residential (Physical / Civic) Address*
24. Mailing Address*

    If unknown, please type 'unknown'.

26. City/Town*
27. Province*
28. Postal Code*
30. Phone Number*
31. Email Address*
33. Are you interested in receiving your tax and utility account correspondence (bills etc.) via email through our eServices program?*

    1. Yes
    2. No

    Sign up for eServices today!

    
    

35. BANK ACCOUNT INFORMATION

    Please verify that your information is correct before submitting it.

37. Name(s) on the Bank Account*

    Include ALL names registered on the bank account.

39. Financial Institution Name*
40. Financial Institution Address
42. Institution / Bank #*

    3 Digits

43. Branch / Transit #*

    5 Digits

44. Account #*

    Up to 12 Digits

46. Not sure how to find your bank account information on your cheque or online deposit form? Please view the image on the right.

47. 
49. Photo or Scan of Void Cheque

    Please attach a photo or scan of the VOID cheque or bank-issued pre-authorization document.

51. TERMS & CONDITIONS
53. Utilities Payment Pre-authorization (UPP): Terms & Conditions

    1. I acknowledge that the Authorization is provided for the benefit of the Town of Diamond Valley and the Processing Institution and is provided in consideration of the Processing Institution agreeing to process debits against my account, as listed above, (the “Account”) in accordance with the Rules of the Canadian Payments Association.

    2. I warrant and guarantee that all persons whose signatures are required to authorize withdrawals from the Account have digitally signed the Authorization below.

    3. I hereby authorize the Town of Diamond Valley to issue pre-authorized debits (as defined in Rule H1 of the Rules of the Canadian Payments Association) (the “pre-authorized debit”) drawn on the Account, for the following purpose: Payment of Utility Account.

    4. I may cancel the Authorization at any time upon providing written notice to the Town of Diamond Valley 10 days prior to the due date.

    5. I acknowledge that provision and delivery of the Authorization to the Town of Diamond Valley constitutes delivery by me to the Processing Institution. Any delivery of the Authorization to the Town of Diamond Valley, regardless of the method of delivery, constitutes delivery by me.

    6. The Town of Diamond Valley will provide to me at the mailing address provided above:

    a. With respect to fixed amount pre-authorized debits, written notice of the amount to be debited (the “payment amount”) and the dates(s) on which the payment amount debited will be posted to my Account (the “payment date”), at least 10 (ten) calendar days before the payment date of the first pre-authorized debit, and such notice shall be provided every time there is a change in the payment amount or the payment date(s).

    b. With respect to variable amount pre-authorized debits, written notice of the payment amount and the payment date(s), at least 10 (ten) calendar days before the payment date of every pre-authorized debit.

    c. With respect to a pre-authorized debit plan that provides for the issuance of a pre-authorized debit in response to a direct action of mine (such as, but not limited to, telephone instruction) requesting the Town of Diamond Valley to issue a pre-authorized debit in full or partial payment of a billing received by me for a payment obligation that meets the requirements of Section 2 of Rule H1, no notice is required.

    7. I acknowledge that the Processing Institution is not required to verify that a pre-authorized debit has been issued in accordance with the particulars of the Authorization including, but not limited to, the amount, or that any purpose of payment for which the pre-authorized debit was issued has been fulfilled by the payee as a condition to honoring a pre-authorized debit issued or caused to be issued by the Town of Diamond Valley on the Account.

    8. Revocation of the Authorization does not terminate any contract for goods or services that exists between me and the Town of Diamond Valley. The Authorization applies only to the method of payment and does not otherwise have any bearing on the contract for goods of services exchanged.

    9. An NSF fee of $25.00, as provided for by the Town of Diamond Valley policy, shall be charged for any installment that fails to be honored by the processing institution.

    10. I may dispute a pre-authorized debit only under the following conditions:

    a. The pre-authorized debit was not drawn in accordance with the Authorization.

    b. The Authorization was revoked.

    c. Pre-notification, as required under Section 6, was not received.

    11. I have attached a photo or scan of a specimen cheque marked “VOID” to this Payor Authorization (the “Authorization”). 

    12. I will inform the Town of Diamond Valley, in writing, of any change in the information provided in this Authorization ten (10) days prior to the next due date of the pre-authorized debit. 

    13. I agree that the information contained in the Authorization may be disclosed to Alberta Treasury Branches as required to complete any pre-authorized debit transaction. 

    14. I understand and accept the terms of participating in this pre-authorized debit plan and agree to be bound by its terms.

    I hereby confirm that the information contained in this form is true and correct to the best of my knowledge.

55. APPLICANT'S DECLARATION
57. Acknowledgement & Agreement*

    I acknowledge that, by typing my name above, I agree to be bound by the Terms & Conditions of the plan as if I had endorsed this document with my own handwritten signature.  I further agree that all of the information on this application is true, accurate and complete to the best of my knowledge.

59. Acknowledgement of additional account holders

    For joint accounts where more than one signature is required on cheques, all required signatures must be provided. I acknowledge by typing the name above that any additional bank account holders have agreed to the Terms and Conditions of the UPP application above, and that such entry is endorsed as if with their handwritten signature.

61. Protection of Privacy Act

    The personal information collected through the Utilities Pre-Authorized Payment Plan (UPP) Application is for obtaining permission to collect utility payments through the Town of Diamond Valley's UPP program. This collection is authorized under section 4(c) of the Protection of Privacy Act. For questions about the collection of personal information, contact the Privacy Office LegislativeServices@DiamondValley.town or 403-933-4348

Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit

* indicates a required field