Fillable Printable Application for Payment of the TV Licence Fee

Application for Payment of the TV Licence Fee

Application for payment of the

Television Licence Fee

by Direct Debit from a Bank Current Account

Television Licence Details

TV Licence Account Reference Number

Full name on the Licence

Address the Licence is to cover

Mailing Address if different

Terms & Conditions and Payment Option

This Direct Debit Agreement will remain in force on a year to year basis until such time as it is cancelled. Any changes to the television

licence fee will apply to all television licences purchased after the date on which the fee comes into force. An Post will notify you, by post,

on an annual basis of the amounts due to be debited from your Bank Account.

Under this agreement you are legally obliged to pay the full cost of a television licence by Direct Debit. Non-receipt of any instalment due

on your television licence fee will result in the revocation of the licence and you will then be obliged to purchase a replacement licence in

full or face prosecution for breach of Wireless Telegraphy Legislation.

In the event of changing your bank or bank account number, please remind your bank of this Direct Debit in order to prevent failure of An

Post payment requests.

The television licence fee may be paid by an annual debit or by instalments.Please tick the box indicating the frequency of direct debiting

that you require, annually, bi-annually, quarterly or monthly. Where a direct debit mandate is being set-up in respect of a renewal licence,

the existing expiry date of the licence will remain unchanged and any arrears due to the date of the set-up will be collected in the first

instalment.

Debit Frequency Annual Bi-annually Quarterly Monthly

Instruction to your Bank to pay Direct Debits

An Post, 1/2 Upper O’Connell St, Dublin 1

Originators Identificat ion No

Bank Account Holder’s Name

Bank Account Number

Bank Sort Code

Name and Address of Bank

The Direct Debit Guarantee

•This is a guarantee provided by your own Bank as a member of the Direct Debit Scheme, in which Banks and Originators of

Direct Debits participate.

•If you authorise payment by Direct Debit, then

oYour Direct Debit Originator will notify you in advance of the amounts to be debited to your account

oYour Bank will accept and pay such debits, provided that your account has sufficient available funds

•If it is established that an unauthorised Direct Debit was charged to your account, you are guaranteed a prompt refund by your

Bank of the amount so charged.

•You can cancel the Direct Debit Instruction by writing in good time to your Bank

I hereby instruct my Bank to pay Direct Debits from my account at the request of An Post. I confirm that the amounts to be

debited are variable and may be debited on various dates. I shall duly notify the Bank in writing if I wish to cancel this

instruction. I shall also so notify An Post of such cancellation.

I agree to the terms and conditions of paying my television licence fee by Direct Debit from my Bank Current Account. I fully

accept my legal obligation to pay the television licence fee in full and that failure to do so may result in revocation of the licence.

In such circumstances, I will then be obliged to purchase a replacement licence in full or face prosecution for breach of Wireless

Telegraphy Legislation.

Customer Signature

Date

Please complete and return to your local TV Licence Records Office

BANKS MAY REFUSE TO ACCEPT INSTRUCTIONS TO PAY DIRECT DEBITS FROM SOME TYPES OF ACCOUNTS