* Denotes that the field is mandatory.
Complete the online form below. Please note there is no need for you to physically sign a Outstanding Rate Assessment Direct Debit Request Service Agreement and submit it to the City of Belmont.
This Agreement contains the terms and conditions on which you authorise the City of Belmont to debit money from your account and the obligations of the City of Belmont under this agreement.

Read the Direct Debit Agreement carefully to ensure you understand these terms and conditions before completing the Direct Debit Request Form.

If you agree to this Direct Debit arrangement which is governed by the terms and conditions of the Agreement outlined above for the City of Belmont (APCA User ID 067205) from your nominated bank account, please select 'I/We agree'.
Service Agreement *
Rates Assessment Number *
Owner 1 *
Owner 2
Postal Address *
Email Address *
Contact Number *
Mobile Number
Amount to be debited *
Commencement Date (Friday only) *
Reason for alternative arrangement *
Frequency of debit (ie Weekly, Fortnightly) *
Financial Institution *
Account Holder Name *
Branch *
BSB Number (6 digits) *
Account Number *
I/We request and authorise the City of Belmont (APCA User ID 067205) to arrange through its own financial institution a debit to the above nominated account, an amount agreed upon with the City of Belmont.

This debit will be made through the Bulk Electronic Clearing System (BECS) from this account held at the financial institution nominated above and will be subject to the terms and conditions of the Direct Debit Agreement.

By accepting below, I/we agree to the direct debit arrangement.
Authorisation *