DIRECT DEBIT BANK AUTHORISATION.
EXACT PAY OPTION.
SIGNATURE.
Your account number(s)
Your Mercury account name
Pay the exact amount owing on your monthly account.
Name of bank account holder
Bank account details from which payments are to be made.
Name of bank
Bank address
For bank use only. Original - retain at branch. Copy - Forward to initiator in post paid envelope.
Signed SignedDate Date
Payer particulars
Bank Branch Account number Suffix
Authorised by holder(s)of the above nominated bank account.
Account number Installation description
Information to appear on the customer’s bank statement (to be completed by Mercury).
Address
Phone number
Postcode
AUTHORITY TO ACCEPT
DIRECT DEBITS
(Not to operate as an
assignment or an agreement)
AUTHORISATION CODE
I/We authorise you, until further notice in writing to debit my/our account with you all amounts which Mercury NZ Ltd (hereinafter referred to
as the initiator) the registered Initiator of the above Authorisation Code, may initiate by direct debit. I/We acknowledge and accept that the
bank accepts this authority only upon the conditions listed on the reverse of this form.
Date received: Recorded by: Checked by: Bank stampApproved 0241
60 1999
MERCURY
0121056
If your suffix only has 2 digits
please insert a zero in the first box.
MCY00002_0623
CONDITIONS OF THIS AUTHORITY
TO ACCEPT DIRECT DEBITS.
1. Mercury NZ Ltd (THE INITIATOR) has authority to direct debit using ANZ authority 0121056
(a) Has agreed to give advance written notice of the net amount of each direct debit, and the date of debiting, at least 5 business
days before the date the direct debit deduction will be initiated on.
(b) Has agreed to give advance written notice of the net amount of each direct debit, and the date of debiting at least 10 business
days, but not more than 2 calendar months, before the date the direct debit will be initiated for all subsequent deductions.
The advance notice will include confirmation that the total due, less any payments received since the date of the invoice, will be
deducted from your Bank account on the due date.
*This date will be at least two days prior to the due date to allow for amendment of direct debits.
(c) May, upon the relationship which gave rise to this Authority being terminated, give notice to the Bank that no further direct
debits are to be initiated under the Authority. Upon receipt of such notice the Bank may terminate this Authority as to future
payments by notice in writing to me/us.
2. THE CUSTOMER MAY:
(a) At any time, terminate this Authority as to future payments by giving written notice of termination to the Bank
and to the Initiator.
(b) Stop payment of any direct debit to be initiated under this authority by the Initiator by giving written notice to the
Bank prior to the direct debit being paid by the Bank.
3. THE CUSTOMER ACKNOWLEDGES THAT:
(a) This authority will remain in full force and effect in respect of all direct debits passed to
my/our account in good faith notwithstanding my/our death, bankruptcy, or other revocation of
this authority until actual notice of such event is received by the Bank.
(b) In any event this authority is subject to any arrangement now or hereafter existing between
me/us and the Bank in relation to my/our account.
(c) Any dispute as to the correctness or validity of an amount debited to my/our account shall not be the concern of the
Bank except in so far as the direct debit has not been paid in accordance with this authority. Any other disputes between
me/us and the Initiator.
(d) Where the Bank has used reasonable care and skill in acting in accordance with this authority, the Bank accepts no
responsibility or liability in respect of:
• the accuracy of information about direct debits on Bank statements
• any variations between notices given by the Initiator and the amounts of direct debits
(e) The Bank is not responsible for, or under any liability in respect of the Initiator’s failure to give written advance notice correctly
nor for the non-receipt or late receipt of notice by me/us for any reason whatsoever. In any such situation the dispute lies
between me/us and the Initiator.
4. THE BANK MAY:
(a) In its absolute discretion conclusively determine the order of priority of payment by it of any monies pursuant to this or any
other authority, cheque or draft properly executed by me/us and given to or drawn on the Bank.
(b) At any time terminate this authority as to future payments by notice in writing to me/us.
(c) Charge its current fees for this service in force from time-to-time.
