Pre-Authorized Payment Form

Payor's Name
Secondary Payor
Service Address
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Terms of Conditions for Pre-Authorized Payments.
I/We will inform the Payee, in writing, of any change in the information provided in this section of the Authorization prior to the next due date of the PAD.

I/We acknowledge that the Authorization is provided for the benefit of the Payee and the Processing Institution and is provided in consideration of the Processing Institution agreeing to process debits against our account, as listed above, (the "Account) in accordance with the Rules of the Canadian Payments Association.

I/We warrant and guarantee that all persons whose signatures are required to authorize withdrawals from the Account have signed the Authorization below.

I/We hereby authorize the Payee to issue Pre-authorized Debits (as defined in Rule H1 (PreAuthorized Debits (PADs) Rule H1 of the Rules of the Canadian Payments Association) (the "PAD") drawn on the Account, for the following purpose: utility account payments.

I/We may cancel the Authorization at any time upon providing written notice to the Payee.

I/We acknowledge that provision and delivery of the Authorization to the Payee constitutes delivery by me/us to the Processing Institution. Any delivery of the Authorization to the Payee, regardless of the method of delivery, constitutes delivery by me/us.

The Payee will provide to me/us, at the address provided in Section 1:
(a) with respect to fixed amount PADs, written notice of the amount to be debited (the "Payment Amount") and the date(s) on which the Payment Amount debited will be posted to our Account (the "Payment Date"), at least 10 calendar days before the Payment Date of the first PAD, and such notice shall be provided every time there is a change in the Payment Amount or the Payment Date(s); (b) with respect to variable amount PADs, written notice of the Payment Amount and the Payment Date(s), at least 10 calendar days before the Payment Date of every PAD; and
(c) with respect to a PAD plan that provides for the issuance of a PAD in response to a direct action of mine/ours (such as, but not limited to, a telephone instruction) requesting the Payee to issue a PAD in full or partial payment of a billing received by me/us for a payment obligation that meets the requirements of Section 2 of Rule H4, no notice is required.

The Payee may issue a PAD monthly in a dollar amount up to a maximum of the actual bill.

I/We acknowledge that the Processing Institution is not required to verify that a PAD has been issued in accordance with the particulars of the Authorization including, but not limited to, the amount, or that any purpose of payment for which the PAD was issued has been fulfilled by the Payee as a condition to honouring a PAD issued or caused to be issued by the Payee on the Account.

Revocation of the Authorization does not terminate any contract for goods or services that exist between me/us and the Payee. The Authorization applies only to the method of payment and does not otherwise have any bearing on the contract for goods or services exchanged.

I/We have certain recourse rights if any debit does not comply with this agreement. I/We have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAD agreement. To obtain more information on you’re my/our recourse rights, I/We may contact your financial institution or visit

I/We agree that the information contained in the Authorization may be disclosed to CIBC as required to complete any PAD transaction.

I/We understand and accept the terms of participating in this PAD plan.

I/We understand that if our Pre-Authorized Payment is returned from the financial institution, it will be removed from the account and a security deposit will be required if within the first year of service. 

I/We understand that if the Pre-Authorized Payment is cancelled by myself, a security deposit will be required if within the first year of service. 
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