2019-04-05_aallard_Kathleen Keefler PAD .pdf

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PRE -AUTHORIZED AGREEMENT  
 
 
 
[X] New Enrollment Pre -Authorized Agreement (PAD) Type: Personal/Household PAD [x]  
 
WHEREAS the undersigned (“ We, Our or Us” ) as used herein refer to :  
 
(Payor): _______________________________________ ; 
 
AND WHEREAS We hereby agree  to grant  Home Care Assistance  access to Our bank account for the 
purpose of allowing Home Care Assistance to debit such account for amounts owing by Us pursuant to 
this Pre -Authorized Agreement;  
 
NOW, THEREFORE, We hereby authorize and agree as follows:  
 
1. Scope  - We acknowledge that this Authorization is provided for the benefit of Home Care Assistance 
and Our financial institution named below ( Financial Institution ) and is provided in consideration of the 
Financial Institution agreeing to process debit s against Our account ( Account ) in accordance with the 
Rules of the Canadian Payments Association.  
 
2. Authority  to Debit Account - We understand that the transaction amount may increase or decrease from 
time to time  because We choose to change the status or nature of Our requested services. We hereby 
authorize Home Care Assistance  to draw  on the Account for the purpose of paying  Home Care 
Assistance amounts owing to it pursuant to the Customer and PAD agreement(s).  
 
3. Cancellation  of Arrangement - This PA D Authorization may be cancelled upon notice by Us. We 
acknowledge that, in  order to revoke this Authorization, We must provide notice in writing to  Home Care 
Assistance . We acknowledge that it could take up to 5 business days after Home Care Assistance  receipt 
of such notice to implement our revocation.  
 
4. Waiver  of Pre -notification - We and Home Care Assistance , agree to waive the pre -notification 
requirement, as set out in Section 7 of Appendix II of rule H4 of the Canadian Payments Association, of 
any debit to Our Account.  
 
5. Validation  by Processing Institution - We acknowledge that the Financial Institution is not required to (i) 
verify that a PAD  has been issued in accordance with the particulars of this Authorization including, but 
not limited to, the amount; (ii) verify  that any purpose of payment for which the PAD was issued has been 
fulfilled by Home Care Assistance  as a condition to honoring a PAD issued on Our Account.  
 
6. Your  Rights of Dispute - A PAD may be disputed by Us under the following  conditions:  
(i) the PAD was not drawn in accordance with Our Authorization; or (ii) the Authorization was revoked.  
 
In order to be reimbursed, We acknowledge that a declaration to the effect that either (i) or (ii) took place, 
must be  completed and presen ted to the branch of the Financial Institution holding Our Account up to and 
including 10 business  days after the date on which the PAD in dispute was posted to Our Account.  
 
We acknowledge that a claim on the basis that Our Authorization was revoked, or a ny other reason, is a 
matter to be  resolved solely between Home Care Assistance  and Us when disputing any PAD after 10 
business days.

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7. Disclosure  of Information Consent - We consent to the disclosure of any personal information that may 
be con tained on  this Authorization to the financial institution and/or financial services partner at which  
Home Care Assistance  maintains its account to be credited with the PADs as far as any such disclosure 
of personal information is directly related to and  necessary for the proper application of Rule H4 of the 
Canadian Payments Association.  
 
8. Confidentiality  – Home Care Assistance agrees to hold all i nformation included in this agreement in the 
strictest confidence and not to disclose it to any person, firm or corporation or to use it except as necessary in 
carrying out account debits as agreed to in this PAD.  
 
 
The details of the Account that Home Care Assistance  is authorized to draw upon are indicated below  
 
Payor Name: ____________________________________ ____  
 
Telephone: __________________________  
 
Address :_____________________________________________________ ________________________  
 
City: ________________ ____ Province: _________________ Postal Code: _______________________  
 
Financial Institution: ________ __________________________  
 
Institution # (3 digits): __________________  
 
Transit (5 digit): ____________________  
 
Account #: ___________________________________________  
 
We understand the terms hereof and acknowledge and agree to participate in the PAD Plan with Home 
Care Assistance . We warrant and guarantee that all persons whose signatures are required to sign on 
Our Account have signed this Authorization below.  
 
IN WITNESS WHEREOF , We have executed this agreement as of the date written below.  
 
 
______ _____________ __ _  ___________________    ____________________  
Client Signature   Name/Title (Print)    Date  
 
 
 
___________________ ___  __________________ __   ____________________  
Client Signature   Name/Title (Print)    Date