Cancellation of Direct Debit Authorization for Payment of Government Rent

Part 1 Authorization Information

Government Rent Reference No.:

- -

*

Effective Date:

*

Bank Account No.:

- -

*

Name(s) of Bank Account Holder(s):

*

Location of Property:

*

Because of:

*

Part 2 Communication Information

Identity:

Owner

Occupier

Agent

*

Name:

*

Contact Tel. No.:

*

Email:

*

Date:

*

Data is provided by “iAM Smart”.

Part 3 Personal Data

(a) The data provided by you will be used for the purpose of cancellation of direct debit authorization for payment of Government rent.

(b)) This department may give the data to other Government bureaux and departments, relevant service contractors and other parties authorized by law to receive it.

(c) Under the Personal Data (Privacy) Ordinance, you have a right to request access to and correction of your personal data. Such requests can be made to the Departmental Secretary of Lands Department at 21/F, North Point Government Office, 333 Java Road, North Point, Hong Kong.

I declare that I have read and understood the above notice.*

Part 4 Declaration

I declare that the information given by me in this application is to the best of my knowledge and belief, both true and correct.*

Signature
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Part 5 Authentication

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*