Customer/Company Details Customer Given Names/Company Name Customer Family Name/ACNABN/ARBN Mailing Address Phone Number Email address (to receive confirmation) Complete this section for rate accounts only Rates Assessment Number Cancellation Date Property Address Complete this section for debtor accounts only Debtor Account Number Debtor Account Cancellation Date I/we acknowledge that this Direct Debit arrangement is governed by the terms of the Direct Debit Service Agreement received from you. Leave this field blank
