Before You Begin

To set up a direct debit , you will need to fill in this application.

You can set up a direct debit for 4 instalments, or one full payment.

Direct debit application for current years rates will not be accepted after 31 December.

The 4 instalment dates are:

30^th September

30^th November

28^th February

31^st May

Please read the Service agreement at the bottom of this form.

Your Details

Name *

Postal address *

Email address *

Mobile phone number

Home phone number

Work phone number

Direct Debit Details and Bank Details

New direct debit, or change?

New direct debit requestChange direct debit

Name of bank *

Bank address

Name bank account held in *

BSB number *

Bank account number *

Payment frequency *

4 InstalmentsFull payment on 15th February

Start date *

Property Details

Property 1 assessment number *

Property 1 address *

Do you want to add more properties?

Yes No

Property 2 assessment number

Property 2 address

Property 3 assessment number

Property 3 address

Property 4 assessment number

Property 4 address

Property 5 assessment number

Property 5 address

Property 6 assessment number

Property 6 address

Property 7 assessment number

Property 7 address

Property 8 assessment number

Property 8 address

Property 9 assessment number

Property 9 address

Property 10 assessment number

Property 10 address

Acknowledgement

Please complete this section to confirm your application.

I have read and understood the service agreement that is listed below this submission. *

I acknowledge all details I have provided are correct, and accept the East Gippsland Shire Council Privacy Statement. *

Service Agreement

Direct Debit :

By signing the direct debit form you allow East Gippsland Shire to take money from your bank account.

We will only take money on a business day, if the date falls on a weekend or public holiday we will take the money on the next business day.

Changes to the Direct Debit:

If we need to change the direct debit we will write you a letter and give you 14 days’ notice of this change.

Please call us on 03 5153 9500 if you have any questions.

If you want to stop or change the Direct Debit:

To stop or change the direct debit or update your bank details you need to tell us in a letter and give us 14 days’ notice.

Your Responsibility:

You need to make sure there is enough money in your bank account for each direct debit. You may be charged fees by your bank if there is not enough money. You should check your bank statement to make sure the right amount of money has been taken out by us.

If your payment dishonours three times, your direct debit will be cancelled and you will need to find another way to pay your account.

Mistakes:

If you think we have made a mistake, you need to call us on 03 5153 9500. You should also write us a letter to explain the mistake. If a mistake has been made, we will refund the money back into your account. If we have not made a mistake, we will write to you to explain the reasons.

Accounts:

You should make sure that a direct debit can be taken from your bank and your account details are correct. Check with your bank if you have any questions about direct debit.

Confidentiality:

Confidentiality means we will keep your information private. We will do what the law says. You can ask for a copy of our Privacy Policy.

Contact Us:

Phone us on 03 5153 9500 or freecall 1300 555 886

or

Write to us at

East Gippsland Shire Council

PO Box 1618

Bairnsdale VIC 3875