Instuction to your Bank or Building Society to pay by Direct Debit

Account Details

Items marked must be completed

Use Of The Form

	Form Ref. No.		349136

	This form can be completed on-line. When completed it should be printed and sent back to the Council.

Account Details

	Name(s) of Account Holder(s)
	Bank/Building Society account number
	Branch Sort Code

Name and full postal address of your Bank or Building Society


	Bank / Building Society

	Address Line 1
	Address Line 2
	Address Line 3
	City / Town
	County
	Postcode

	Account Reference Number

Preferred Payment Date

	This is not part of the instruction to your Bank or Building Society

	I wish to pay monthly on or immediately after this date (select one from pull down list : 1st, 15th or 25th)

	If the 15th or 25th date is selected, payment will not be called for in March due to Annual Billing and the last payment will be adjusted to February.