PRE-AUTHORIZED DEBIT AGREEMENT (PAD)Pre-Authorized Debit Agreement (Pad) • November 13th, 2019
Contract Type FiledNovember 13th, 2019CLIENT NAME, If other than the PAYOR: Client #:_ _ 1. PAYOR INFORMATION: Name: _ _ __ Address: _ _ __ City: _ Prov: Postal Code: _ Phone: _ __ 2. BANK ACCOUNT INFORMATION: Transit # : (5 digits) Financial Institution # : _ (3 digits) Account # : _ Financial Institution: _ _ _ _ _ Address: _ _ _ _ Chequing: _ _ Savings: 3. PRE-AUTHORIZED DEBIT (PAD) DETAILS: You, the Payor, authorize Victoria Lifeline to debit the bank account identified above for payment of yourInitial Payment $_ You, the Payor, authorize Victoria Lifeline to debit the bank account identified above for the ongoing Monthly Monitoring Fee $ You, the Payor, may revoke your authorization at any time in writing or by phone subject to provision of 30 days notice in accordance with the Victoria Lifeline Service Agreement. 4. WAIVER OF PRE-NOTIFICATION: You, the Payor, waive any and all requirements for pre-notification of debiting, including, without limitation, any changes in the amount of the PAD due to a se