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PUPP- Pre-Authorized Utility Payment Plan Application

  1. Section A- Property Identification
    Please fill in required field below
  2. Section B - Applicant's Personal Information
    Please fill in required fields below
  3. Primary person on title who should receive the bills. (Note: only 1 person can be listed as primary owner)
  4. OR
  5. Applicants Name:
  6. If Primary Owner is a business, I declare that I am a director of the above-named business ___ (Please Initial)
  7. Section C - Applicant's Bank Account Information
    Canadian Banks Only
  8. Upload copy of void cheque.
  9. Ensure to provide a copy of a 'void' cheque (handwritten bank account information will not be accepted)
    Important: It is the responsibility of the account holder(s) to confirm that payments are being withdrawn from their bank account.
  10. Section D- Authorization
    By my signature below I acknowledge that I have read and understood the following:
  11. Section E - Condition of the Pre-Authorized Utility Payment Plan*
    Please read carefully
  12. Electronic Signature Agreement
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  13. For Office Use Only
  14. Copy of PUPP Application given to owner
  15. Application received by:
  16. Notes:
  17. FOIP Notification:
    Your personal information is protected by the privacy provisions of the Freedom of Information and Protection of Privacy Act. The personal information you provide on this form is being collected under the authority of Section 33(c) of the Freedom of Information and Protection of Privacy Act. This information will be used for the purposes of collecting utility payments. This form is deemed transitory and will be destroyed upon cancellation of PUPP account. If you have any questions about the collection or use of this information please contact the FOIP Coordinator, at the MD of Bighorn at 403-673-3611.
  18. Leave This Blank:

  19. This field is not part of the form submission.