Direct Debit Form – CB AM4 Forms

Form to
Complete

Direct Debit Instruction

In order to set up a Direct Debit Instruction, you must be the account holder of a personal bank or building society account. If you are not the only required signatory on your account, finance department on 01536 607992.

Bank or Building Society Name *

Branch Name *

Town, city or branch identifier

Sort Code *

Account Number *

Account Holder's Name(s) *

As shown on statement. Use commas between multiple names

Full Name of Client *

Name of client receiving the services

Postcode of Client *

Postcode where services are received (to ensure we match the payments to the correct account)

Email address for Invoices and DD Confirmation *

Email

Confirm Email

Agreement of creation of this Direct Debit Instruction *

Please pay The Care Bureau Limited, Direct Debits from the account detailed in this instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this instruction may remain with The Care Bureau Limited and, if so, details will be passed electronically to my Bank/Building Society. Banks and Building Societies may not accept Direct Debit Instructions for some account types. By agreeing to this Direct Debit Instruction you are confirming that you are the account holder and that you are the only person required to authorise debits from this account

Signature(s) *

Clear Signature

Use your mouse, or finger // stylus on touchscreen devices.

Direct Debit Guarantee *

Read & Understood

Organisations using the Direct Debit Scheme go through a careful vetting process before they’re authorised, and are closely monitored by the banking industry. The efficiency and security of Direct Debit is monitored and protected by your own bank or building society.

The Direct Debit Guarantee applies to all Direct Debits. It protects you in the rare event that there is an error in the payment of your Direct Debit*.

1) The Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits

2) If there are any changes to the amount, date or frequency of your Direct Debit, The Care Bureau will notify you (normally 10 working days) in advance of your account being debited or as otherwise agreed. If you request The Care Bureau to collect a payment, confirmation of the amount and date will be given to you at the time of the request

3) If an error is made in the payment of your Direct Debit, by The Care Bureau 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

4) If you receive a refund you are not entitled to, you must pay it back when The Care Bureau asks you to

5)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.

* The Guarantee covers Direct Debit payments. It cannot be used to address contractual disputes between you and the billing organisation.

dateblock