Ach Credit Authorization Form For Electronic Funds Transfer Form - City Of Cincinnati Income Tax Division

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City of Cincinnati

Income Tax Division

ACH Credit Electronic Filing Program

Click on the fields below and type in

your information. Then print the form

and mail it to our office.

ACH CREDIT AUTHORIZATION FORM FOR ELECTRONIC FUNDS TRANSFER

TAXPAYER INFORMATION

_________________________________________________________________________________

TAXPAYER ACCOUNT NAME:

CINCINNATI ACCOUNT NUMBER: ________________________________________________________________________________

______________________________________________________

SOCIAL SECURITY OR FEDERAL IDENTIFICATION NUMBER:

NAME OF FINANCIAL INSTITUTION YOU WILL BE USING FOR ACH TRANSACTIONS: ___________________________________

CONTACT INFORMATION

PRIMARY CONTACT PERSON: ___________________________________________________

TITLE: ________________________

ADDRESS: __________________________________________________ TELEPHONE NUMBER: (

) ___________________

CITY: ________________________________________

STATE: ________________

ZIP CODE: ____________________________

AUTHORIZATION STATEMENT

I hereby authorize the contact person listed on this form and the financial institutions involved in processing of my payments to receive confidential information

necessary to effect electronic payment of withholding taxes, answer inquiries, and resolve issues related to enrollment and payments. If signed by a corporate officer,

partner or fiduciary on behalf of the taxpayer, I certify that I have the authority to execute this authorization on behalf of the taxpayer. This authorization is to remain in

full force until the City of Cincinnati Finance Department has received written notification from me of termination in such time as to afford a reasonable opportunity to

act on it.

__________________________________________________________________________________

Date ____________________________

Taxpayer Signature

___________________________________________________________________________________

Title ____________________________

Printed Name

Mail the completed registration form to:

ACH CREDIT ELECTRONIC FILING PROGRAM

CITY OF CINCINNATI

INCOME TAX DIVISION

805 CENTRAL AVENUE SUITE 600