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2. 
4. Application Date*
   Application Date
6. Property Tax Roll Number*
10. Payor Information
12. First Name*
13. Last Name*
15. Civic Address*
17. Mailing Address (if different than property address)
19. Street Address or P.O. Box
21. City
22. Province
23. Postal Code
25. Phone Number*
26. Email Address*
30. Payee Name and Address (the "Payee")

    City of Brooks
    Box 879
    Brooks, AB, T1R 1B7

    Contact: 403-362-3333; taxes@brooks.ca

34. Cancel Payment

    (15 days notice is required before the next PAD will be issued)

36. The Payor hereby cancels this Payor's PAD Agreement effective:*
    The Payor hereby cancels this Payor's PAD Agreement effective:
38. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
40. Electronic Signature*
41. Date*
    Date
43. Electronic Signature
44. Date
    Date
46. NOTE

    If you need a refund for your payments to date, please also complete the Tax Refund Request Form.

Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

* indicates a required field