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Pre-Authorized Debit Agreement (PAD) for Municipal Taxes

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

You have two Pre-Authorized Payment options. 

Budget plan

Monthly payments starting on the first open business day of your chosen month. 

Payments are calculated as follows :

  • January to June = previous year taxes divided by 12 months
  • July to December = current taxes - amount paid / 6 months

Regular plan

4 annual payments - February, April, June, August starting on your chosen installment date

The withdrawal will be made on the due date shown on the invoice

The municipality may cancel this authorization.

In order to adhere to one of these two plans, your taxes must be paid up to date. 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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