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Pre-Authorized Debit Agreement (PAD) for Daycare

I authorize the City of Clarence-Rockland to make pre-authorized debits (PAD's) in my account. This authority is to remain in effect until the City of Clarence-Rockland has received written notification from me/us of its change or termination. This notification must be received at least fifteen (15) business days before the next debit is scheduled at the address provided below. 

I/we may obtain a sample cancellation form, or more information on my/our right to cancel a PAD Agreement at my/our financial institution or by visiting 

Account holder (s) and account details


I, the undersigned, authorize the City of Clarence-Rockland to make pre-authorized dbits (PADs) in my account at the financial institution named above, at the following frequency. 

  • Monthly (30th, of every month)

Each withdrawal will correspond:

  • To the outstanding amount

The municipality may cancel this authorization

In order to adhere to one of these two plans, your daycare account must be paid in full. After two insufficient funds (N.S.F.) withdrawals we will cancel your pre-authorized payment plan. 


I have certain recourse rights if any debit does not comply with this agreement. For example, you have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAD Agreement. To obtain more information on your recourse rights, you may contact your financial institution or visit



As the holder of the bank account, I confirm that the information provided in this form is accurate and complete. I confirm that all persons whose signature is required for the bank account indicated above have signed this authorization. By signing below, I acknowledge having read the Pre-Authorized Debit agreement - Retail and I agree to be bound by it. I undestand that a waiting period may apply before the first debit. 


Signature of the holder(s)


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