(416) 244-5333

135 La Rose Avenue Etobicoke, Ontario Canada M9P 1A6

Pre-Authorized Debit Form

Please complete all applicable sections to instruct your financial institution to make payments directly from your account. Complete the applicable payment options and initial in the box provided.

Sign and return the completed form with a blank cheque marked “VOID” to the payee.

If the account from which payments are to be made is with Ukrainian Credit Union Limited, you need only complete this form using your credit union chequing account number – no blank cheque need be attached.

St. Demetrius Ukrainian Catholic Church

135 La Rose Avenue
Toronto, Ontario M9P 1A6

(416) 244-5333

Account Number of Payee to be Credited at Ukrainian Credit Union Limited: 01972 828 3791142

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Financial Institution Branch to be Debited


Account Holders - Payors


  1. I (We) as the account holder(s), authorize the payee and the above-noted financial institution to debit my (our) account, at the above indicated branch of the financial institution, under terms and conditions agreed to by me (us) with the payee until such time as written notice is given by me (us).
  2. I (We) warrant that all persons signatures are required to sign on this account have signed this form.
  3. The branch of the financial institution at which I (we) maintain the account is not required to verify that the payment(s) are drawn in accordance with this authorization.

    I understand and agree that if I am authorizing my account with Ukrainian Credit Union Limited to be debited, the said debit may be made by way of a transfer from my account to the payee's account and Ukrainian Credit Union Limited may provide the payee with my name and corresponding account number to enable the payee to verify and reconcile my payments.
Fixed Date and Frequency
  1. I (We) will notify the payee in writing of any changes in the account information or termination of this authorization prior to the next due date of the pre-authorized debit.
  2. Items charged will be reimbursed subject to notification by me (us) to the branch of account within 90 days under any of the following conditions:
    1. I (we) never provided the authorization to the payee.
    2. The pre-authorized debit was not drawn in accordance with this authorization.
    3. My (our) authorization was revoked.
    4. The debit was posted to the wrong account due to incorrect account information supplied by payee.
    I understand that a written declaration to the effect that one of (a), (b), (c) or (d) took place must be given to my (our) financial institution.
  3. I (We) acknowledge that delivery of this authorization to the payee constitutes delivery by me (us) to the above noted financial institution.
Clear Signature
Signature(s) of Account Holder(s)
Clear Signature
Signature(s) of Account Holder(s)