Direct Debit Form

Who is this form for?

Please complete this form if you wish to sign up to direct debit payments for your rent.

Protecting your data?

By completing this form you acknowledge that we will follow our responsibilities under data protection legislation. We will store the information securely, share it with partners and other statutory agencies where we have the right under law to do this, use it only for the purpose it was provided and process it as set out in our privacy policy. For more information please see our privacy policy on our website www.berneslaihomes.co.uk
  • 1. About you
  • Title *

  • First Name *

  • Last Name *

  • Phone number

  • Your address

  • Date of birth *

  • Berneslai Homes Reference

  • 2. Your bank and direct debit details
  • How often do you want to pay your rent?

  • Which day of the week do you want to pay?

  • Which day of the week do you want to pay?

  • What day of the month do you want to pay?

  • When do you want the direct debit to start? Please note we cannot set up a direct debit until at least 12 working days after your request *

  • Name(s) of account holder(s):

  • Bank/Building Society Account number:

  • Branch sort code:

  • Name and full postal address of your Bank/Building Society:

  • By ticking the box below I confirm that I wish to pay allpay 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 allpay Limited and, if so, details will be passed electronically to my Bank or Building Society.