Required fields are marked with asterisks (*)

Authorization to Release Information Form

Separate forms must be completed for each property
Not to be used for commercial purposes, i.e. lawyer, mortgage company, realtor etc.

Property Owner / Company Name(s):

Civic Address of Property:

Property Roll Number:

Mailing Address for Correspondence:

Phone Number:

Email Address:

A/R Account Number (s):

For the above account(s), I/we authorize (name and relationship)

Permissions granted to authorized individuals (Check all that apply):

Discuss my/our account information with the Township of Huron-Kinloss

Receive my/our account information from the Township of Huron-Kinloss (ex. statements, bills, etc.)

Make changes to account information/give direction to the Township of Huron-Kinloss (ex. mailing address preauthorized payments, etc.)

By initialing this box, I verify that I understand I must notify the Township of Huron-Kinloss in writing if I choose to change or revoke authorizations made above.

I am:

Property Owner

Company Officer (with authorization to bind the corporation)

Executor/Trustee/POA (must provide legal documentation)

Owner Signature(s)

Clear

Date

Company Officer Position (if applicable):

Personal information is collected under the authority of the Municipal Act, 2001 for the purpose of creating a record to be used for authorizing the release of property tax or utility account information to people other than the property owner. Questions about the collection of the personal information may be addressed to the Clerk of the Township of Huorn-Kinloss 21 Queen St. Ripley ON N0G 2R0 or (519) 395-3735.

Authorization to Release Information Form

*Separate forms must be completed for each property***Not to be used for commercial purposes, i.e. lawyer, mortgage company, realtor etc.**

Separate forms must be completed for each property
Not to be used for commercial purposes, i.e. lawyer, mortgage company, realtor etc.