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Direct Debit Request online form

Direct Debit Request online form

This application will take approximately five minutes to complete

Request and Authority to debit the account named below to pay Brimbank City Council.

Account details

Type of account (required)

Debtor number

Full Name (required)

Assessment number (required)

Property address (required)

Phone number

e.g. 0414 678 345 or 03 9249 4000

Email (required)

Request and authority to debit

Surname or company name (required)

Given name or ACN/ABN (required)

Date of birth (required)

Day

Month

Year

Bank details of account to be debited

Account holders name (required)

BSB number (required)

Account number (required)

Savings or Cheque account only

Payment details

Frequency of deduction (required)

What is the amount to be deducted (if required)

Declaration

Read the Direct Debit Request Service Agreement.

I, hereby declare that I have read and understood the terms and conditions governing the debit arrangements between you and Brimbank City Council as set out in this request and in your direct debit request service agreement. (required)

Yes

Leave this field blank

Last updated: 2 February 2023 - 3:47pm

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Direct Debit Request online form

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