Direct Debit

request form
Customer details
Water Corporation account number:

(This number is located on the top

right hand corner of your account)

Given name/s:

Surname:

Postal address:
Postcode:

Phone number:

TO SET UP DIRECT DEBIT VIA CREDIT CARD VISIT MYWATER.COM.AU

OR CALL 13 13 85
Financial institution account details (e.g. bank, credit union etc)
Name of financial institution:
Address of financial institution:
Name of bank account holder:
Title of account to be debited: (e.g. J Citizen)
BSB number:

Account
number:

If you are unsure of these details, please contact your financial institution for assistance.

Property details: (if this is the same as your postal address please write as above)
Unit/Street no.

Street name

Suburb

Postcode

PAYMENT AUTHORISATION
PART A - Payment choice (this section must be completed by the bank account holder)
Please tick one of the two boxes below:

Pay bills when due The exact amount of the bill is automatically deducted from the
nominated account on the due date. Tenants paying water use bills must select this
method.
Or
Payment by regular instalments Nominate the amount to pay in weekly, fortnightly
or monthly payments (sufficient to cover the bills). This payment method is not
available to tenants paying water use bills.
How often you would like to make
a payment? (tick a box)

Weekly

Please enter the amount you would like

to pay and the start date (This request
may take up to five business days to
process)

Fortnightly

$______

Start
date:

Monthly

__ /__ /__

PART B Declaration of customer (this section must be completed)

I/We declare that:
I am/We are the Owner or an authorised person in relation the property in respect of
which this Direct Debit request is made or an adult person nominated by the Owner for the
purposes of consenting to the above direct debit plan.

I/We give consent for the Water Corporation to apply funds withdrawn in accordance
with this Direct Debit request to the payment of my account.

I/We authorise and request that this Direct Debit request remain in place until cancelled
or otherwise altered in accordance with the Direct Debit Request Service Agreement.

I/We understand that Direct Debit is only a method of payment and is not a formal
payment arrangement to clear overdue charges on an account and that a separate
payment arrangement may need to be entered into in relation to outstanding charges,
in addition to this Direct Debit request.

I/We acknowledge that it may take up to five business days to process this Direct Debit
request.

The information provided in this Direct Debit request is true and correct.

I have read the Direct Debit Request Service Agreement and agree to be bound by its
terms, and I make the above declarations which are true and correct.
Signature/s:

x_____________ x ______________

Date: ___/___/___

Name/s:

x_____________ x ______________

Date: ___/___/___

PART C - Declaration of bank account holder/s (this section must be completed)

I/We declare that:

I am/We are the holder/s of the bank account to be debited; or in the case of where
the bank account holder is not a natural person (i.e. a body corporate), I am / We are
duly authorised to make this request.

I/We give consent for the Water Corporation (User ID 208343) to arrange for funds to
be withdrawn from the above bank account through the Bulk Electronic Clearing System in
accordance with this Direct Debit request, and applied to the payment of the customer
account nominated in this Direct Debit request.

I/We authorise and request that this Direct Debit request remain in place until cancelled
or otherwise altered in accordance with the Direct Debit Request Service Agreement.

I/We understand that Direct Debit is only a method of payment and is not a formal
payment arrangement to clear overdue charges on an account, and I/we understand that
if the account has outstanding charges I/we may need to arrange for a separate payment
arrangement in addition to this Direct Debit request.

I/We acknowledge that it may take up to five business days to process this Direct Debit
request.

The information provided in this Direct Debit request is true and correct.

I/We have read the Direct Debit Request Service Agreement and agree to be bound by
its terms, and I make the above declarations which are true and correct.

Signature/s:

x____________ x ______________

Date: ___/___/___

Name/s:

x____________ x ______________

Date: ___/___/___