Town of Coaldale Utility Pre-Authorized Debit Cancellation Form

Your name, home phone number, home address and postal code are collected under the authority of Section 33(c) of the Freedom of Information and Protection of Privacy Act.

This information will be used in the administration of the Town of Coaldale programs.

If you have any questions about this collection, contact the FOIP Coordinator, Town of Coaldale, 1920-17th Street, T1M 1M1 or 403-345-1300.

I/we hereby cancel my/our authorization to issue pre-authorized debits, either recurring, or one-time payments against the following account number.
I/we acknowledge that this cancellation does not terminate any other obligation that I/we have with the Town of Coaldale.