Direct Debit Authorization Form - City Of Munroe Falls printable pdf download

Direct Debit Authorization Form - City Of Munroe Falls

DIRECT DEBIT AUTHORIZATION

City of Munroe Falls

Income Tax Department

I (we) hereby authorize the City of Munroe Falls Income Tax Department to

automatically deduct the payment amount shown on the Payment Plan

Agreement Number ________, dated _____/______/_____, from my

Checking/Savings account (listed below) on or about the fifteenth of each month,

(or the previous Friday if the fifteenth falls on a Saturday or Sunday).

I (we) understand that this agreement shall remain in full force and effect until the

terms of the Payment Plan Agreement, referenced above, have been completely

fulfilled.

Monthly payment amount: ________________

________________________________

_______________________

Financial Institution Name

Branch

_______________________________

________________________

Routing Number

Account Number

Checking Account ___________________

Savings Account_______________

(Attach a copy of a Voided Check or Savings Deposit ticket)

I have read the above statement and fully understand that I authorize the City of

Munroe Falls Income Tax Department to debit and/or credit my Checking

/Savings account as necessary to fulfill the terms of the Payment Plan

Agreement.

______________________________________

Signature

______________________________________

Print Name

Date

Print Name

Date

______________________________________

Social Security Number

Direct Debit Authorization Form - City Of Munroe Falls