Pre Authorized Debit Form Template – Canada

The Pre Authorized Debit Form Template – Canada is offered in multiple formats, including PDF, Word, and Google Docs. These formats are designed to be both customizable and ready for printing, ensuring they cater to your specific requirements effortlessly.

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Sample

Pre Authorized Debit Form Template – Canada

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1. Account Holder Information


2. Financial Institution Information


3. Debit Details


4. Authorization Statement

5. Pre-Authorization Agreement

6. Cancellation Process

7. Confidentiality Agreement

8. Contact Information

9. Signatures and Declaration


PDF

WORD

Examples

Pre Authorized Debit Form Template – Canada (1)
Customer Information:
[Customer’s Name]
[Customer’s Address]
[Customer’s City, Province, Postal Code]
[Customer’s Phone Number]
[Customer’s Email Address]
Payee Information:
[Business Name]
[Business Address]
[Business City, Province, Postal Code]
[Business Phone Number]
[Business Email Address]
Authorization:
I, [Customer’s Name], hereby authorize [Business Name] to debit my bank account for the payments as outlined below.
Account Information:
Bank Name: [Bank Name]
Account Number: [Customer’s Account Number]
Transit Number: [Transit Number]
Payment Details:
Payment Amount: [Amount] CAD
Frequency: [Weekly/Bi-weekly/Monthly]
Start Date: [Start Date]
End Date: [End Date or “Until Further Notice”]
Cancellation Policy:
I understand that I can cancel this authorization at any time by providing written notice to [Business Name] at least [Notice Period] in advance of the next scheduled debit.
Signature:
__________________________
[Customer’s Signature]
Date: [Date]
Pre Authorized Debit Form Template – Canada (2)
Customer Information:
[Customer’s Full Name]
[Customer’s Residential Address]
[City, Province, Postal Code]
[Phone Number]
[Email Address]
Payee Information:
[Company Name]
[Company Address]
[City, Province, Postal Code]
[Phone Number]
[Email Address]
Authorization:
I, [Customer’s Full Name], authorize [Company Name] to initiate debit entries from my account as specified below.
Bank Account Details:
Financial Institution: [Bank Name]
Account Type: [Checking/Savings]
Account Number: [Account Number]
Routing Number: [Routing Number]
Payment Structure:
Amount to be Debited: [Amount] CAD
Debiting Frequency: [Specify Frequency – Weekly/Bi-weekly/Monthly]
Starting From: [Start Date]
Duration: [Number of Payments/Indefinite]
Right to Cancel:
I acknowledge that I have the right to cancel this pre-authorized debit agreement by providing written notice to [Company Name] at least [Notice Period] prior to the next scheduled transaction.
Authorization Signature:
__________________________
[Customer’s Signature]
Date: [Date]

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Pre Authorized Debit Form Template - Canada