Required fields are marked with asterisks (*)

Authorization to Release Information

This form is to be used when a Property Owner wishes to provide authorization for their property tax or utility account information to be released to a third party.

*Separate forms must be completed for each property.

**Not to be used for commercial purposes, i.e. lawyer, mortgage company, realtor, etc.

Property Owner/Tenant/Company Name(s):

Property Address:

Mailing Address (if different than property address):

Phone Number:

Email:

Property Roll Number:

Utility Customer Number:

For the above referenced account(s), I/we authorize:

Relationship to you or the company:

Please allow the above referenced representative to perform the following (check all that apply):

Discuss my/our account information with the Municipality of Kincardine (example: account balance)

Receive my/our account information from the Municipality of Kincardine (including changing the method of receiving bills and changing mailing/email address).

Make changes to account information (example: enrolling in pre-authorized payments or changing banking information).

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

I am a:

Property Owner

Tenant

Company Officer (I am authorized to bind the corporation)

Executor/Trustee/POA (must provide legal documentation)

Online Form Submission Statement:

By submitting this online form to the Municipality, I acknowledge that the submission is deemed to be a substitute for my signature on the online form and signifies that I have read, understood and agreed to the terms and conditions of the online form. If the user is submitting this form on behalf of a corporation, the user acknowledges they have the authority to bind the corporation.

Please confirm you have read and accept the Online Form Submission Statement

Yes, I have read and accept the Online Form Submission Statement

Name:

Date: MM/dd/yyyy

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 relase of property tax or utility account information to persons other than the property owner. Questions about the collection of personal information may be addressed to the Clerk of the Municipality of Kincardine, 1475 Concession 5, RR 5 Kincardine, ON N2Z 2X6 Phone: 519-396-3468.