Annual Rates Payment Option And Direct Debit Application Form

The City of Busselton collects personal information to process this form and provide the requested services. Information may be used for related City business purposes or disclosed where authorised by law. To learn how your personal information is handled, access the City’s Privacy Statement or contact the Privacy Officer at privacy@busselton.wa.gov.au.

Property and Owner Details

Reference number*

Property address*

Contact name*

Contact number*

Contact email*

Payment Options

The Pay My Rates page on the City of Busselton website contains further information about the different options provided below.

https://www.busselton.wa.gov.au/council/rates/pay-my-rates.aspx

Please choose an instalment option from the following*

Option 1 Full Payment
Option 2 Four Instalments
Option 3 EasyRates Weekly
Option 4 EasyRates Fortnightly
Option 5 EasyRates Monthly

I understand that the options above have the set payment dates and amounts that are shown on my annual rate notice, and that these cannot be changed.*

I Understand

Direct Debit Details

Please fully complete this form and submit on or before the Payment Option registration date stated on the annual notice.

By submitting this request, you agree to the Direct Debit Request Service Terms and Conditions here:

https://www.busselton.wa.gov.au/documents/12858/direct-debit-terms-and-conditions

Agreement with terms and conditions*

I have read and agree to the terms and conditions

Bank BSB number*

Bank account number*

Bank account name*

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