Direct Debit Request

"*" indicates required fields

Step 1 of 2

Customer Name*

First Last

Postal Address*

Street Address City County / State / Region ZIP / Postal Code

Home Phone

Mobile Phone*

Email*

BANK ACCOUNT

Financial Institution*

Account Name*

Account Number*

BSB*

This field is hidden when viewing the form

Account Number Old*

This field is hidden when viewing the form

BSB Old*

It will not be used

Signature(s)*

All named account holders to provide signatures

PREFERRED PAYMENT OPTIONS

Choose your payment options*

Rates

Childcare

Debtor

Misc Payment

Property number*

Debtor No / other

Address*

Street Address City County / State / Region ZIP / Postal Code

Frequency*

Weekly and Fortnightly available on Friday only. Monthly deductions occur on 28th, or closest working day

Amount*

Please enter a number greater than or equal to 0.

Commencing*

Final Payment Date*

Or continuous

Yes

Authorisation

Consent*

I/we request and authorise Central Coast Council (User Id 064381) to arrange for agreed payment option to be debited from the account at the financial institution / credit card issuer identified above.

Signature(s) 1*

Signature 2

Date*

Privacy Collection Statement

We are committed to protecting your personal information. By providing your details on this form, you agree to its collection, storage, and use for the specified purpose. Your data will be handled in accordance with statutory requirements.  We will not share your information without your explicit consent, and we maintain strict security measures to safeguard your privacy.

Direct Debit Request