Rent account

Name(s) of account holder(s) *

Address and postcode of account holder(s) *

Are you setting up this direct debit to pay your own rent? *

Yes

Are you the sole account holder?

Yes

If you are setting up this direct debit to pay rent on behalf a Midland Heart tenant please enter their name or names here

Please enter the address and postcode of the Midland Heart property which you want to set up this direct debit for

If you are not the sole account holder please tick this box to confirm you have the permission of the joint account holder to set up this direct debit *

Bank or building society account number *

Branch sort code *

Name of your bank or building society *

Address and postcode of your bank or building society *

Instruction to your bank or building society

Date of first payment to be made - please note this must be 14 days after the day on which you are completing this form *

Amount of first payment *

Date of regular direct debits - please enter the date (i.e. 2nd) if monthly or day (i.e. Monday) if weekly when you want the direct debit to be taken from your account *

Amount of regular direct debit - please note this should cover the full amount of your rent and and service charges as well as the amount of any payment agreements you have in place * *

Please enter the 10 digit reference number found on the bottom left hand side of your Midland Heart rent card *

By completing and submitting this form you understand the following:

The initial payment will come out of your account on the date you have entered above. Further payments will be taken from your account on the day of the month you have entered and for the amount you have specified – please note this amount should cover the entire cost of your rent and service charges and any payment agreements you have in place. ALLPAY LIMITED will appear on your bank statement against the Direct Debit. On submitting this form you will complete the set-up of your Direct Debit instruction with us. We will then send you written confirmation of this. In future, if the payment dates, amount or frequency of your Direct Debit changes, we will give you 10 working days notice in advance of your account being debited. In the event of any error, you are entitled to an immediate refund from your Bank or Building Society. You have the right to cancel at any time and this guarantee is offered by all the banks and building societies that take part in the Direct Debit scheme. A copy of this guarantee will be sent along with your confirmation. Completing this form fraudulently or without the permission of the account holder/s may result in legal action being taken against you. You are responsible for checking that the payment details, amounts and frequencies are correct before you submit this form. Midland Heart will use this information as you have entered it.

Rent account

Ask about rent account

Setting up a Direct Debit

By completing and submitting this form you understand the following:

Applying for Universal Credit