Post Dated payment form

TOWN OF LEADING TICKLES, POST DATED CHEQUES /CREDIT CARD PAYMENTS

I, ________________________________________ am giving Dianese Cook, Town Clerk/Manager, my credit card information to take automatic payments of $ ________________ a month for (# of months) __________ from my credit card, starting (date) _______________

to , _______________________ for payment on my town taxes.

Credit Card Information: #_______________________________ expiry date: _____________________________ 

or

I, __________________________________ am giving Dianese Cook, Town Clerk/Manager, (# of Cheques) ___________, to pay my town taxes each month.

Cheque #'s and Dates:  ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Signature of Owner: _________________________________________ Date: _______________________

Signature of Town Clerk/Manager: _____________________________ Date: ________________________