Lifeline Amendment Request form

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Customer ID – if available

Name of Applicant *

Address *

Post code *

Email Address if applicable

Would you prefer communication through Email *

Yes

Is the bank account you wish to pay from in your / your company’s name? *

Yes

You answered no to this question, and as you do not have authority to set up a Direct Debit on this account you will have to download, complete and return a paper Direct Debit application mandate. This is available on the following link.Direct Debit Mandate.

Are you the only person required to authorise Direct Debits? *

Yes

Are you applying to notify us on behalf of someone else? *

Yes

If yes, please provide the following.

Your Full Name *

Address *

Postcode *

Contact Telephone Number *

Email Address *

Relationship to applicant *

If you would like to pay via Direct Debit, please fill in the fields below

Bank/Building Society account number *

Branch Sort Code *

Account Name *

Branch *

E.g HSBC

Which type of account is it? *

Business

Personal

Life Line – Payment Frequency *

Monthly

Annually

Person completing the form *

Contact Address *

The Direct Debit Guarantee

This Guarantee is offered by all Banks and Building Societies that accept instructions to pay Direct Debits.
If there are any changes to the amount, date or frequency of your Direct Debit Merthyr Tydfil County Borough Council will notify you 10 working days in advance of your account being debited or otherwise agreed. If you request Merthyr Tydfil County Borough Council to collect a payment, confirmation of the amount and date will be given to you at the time of the request.
If an error is made in the payment of your Direct Debit, by Merthyr Tydfil County Borough Council or your Bank or Building Society, you are entitled to a full and immediate refund of the amount paid from your Bank or Building Society. - If you receive a refund you are not entitled to, you must pay it back when Merthyr Tydfil County Borough Council asks you to.
You can cancel a Direct Debit at any time by simply contacting your Bank or Building Society. Written confirmation may be required. Please also notify us.

Do you authority to cancel this instruction *

Yes

Request a replacement Item (Please state what items need replacing) *

I agree that the information above is correct. *

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Lifeline Amendment Request form

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The Direct Debit Guarantee