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Water Pre-Authorized Payment Form

If you are interested in setting up a water and wastewater Pre-Authorized Payment Form please complete the following. Make sure to include a pre-authorized debit or copy of a void cheque to the upload field at the bottom of the form.

If you have any questions and/or concerns please reach out to us via email at or phone 519-631-4860.


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In this Authorization, "I", "me" and "my" refers to each Account Holder who signs below. If more than one signature is required for the account, all must provide an authorized signature. I warrant and guarantee that all person(s) whose signatures are required to sign on the account have signed this Authorization.

I authorize the Municipality of Central Elgin and the financial institution designated This notification must be received at least ten (10) business days before the next debit is scheduled at the address provided above. This authority is to remain in effect until the Municipality has received written notification from me of its change or termination, subject to providing notice of ten (10) business days. The municipality reserves the right to change/cancel any agreement within ten (10) business days of written notice sent to the account holder.

I understand that the Municipality will levy a service charge (plus applicable interest) against my account upon any payment returned by the banking system and that this agreement may be deemed null and void. 

Any personal information provided on this form is collected, used and disclosed in accordance with the Municipal Freedom of Information Protection of Privacy Act (MFIPPA). We will not sell, share , or rent your personal information to any third party. The Municipality will only use or disclose your personal information in accordance with what is permitted under MFIPPA.

You have certain rights if any debit does not comply with this agreement. For example: you have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAP agreement. To obtain more information on your recourse rights, contact your fincial institution or visit