Webfile Authorixation Form For Electronic Funds Transfer Form - City Of Cincinnati Income Tax Division

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City of Cincinnati

Income Tax Division

Click on the fields below and type in your information.

Enter one numeric character in each of the boxes

below for Bank Account Number and Routing Transit

TELEFILE/WEBFILE AUTHORIZATION FORM FOR ELECTRONIC FUNDS TRANSFER

WEBFILE AUTHORIZATION FORM FOR ELECTRONIC FUNDS TRANSFER

TAXPAYER INFORMATION

TAXPAYER ACCOUNT NAME:

CINCINNATI ACCOUNT NUMBER:

SOCIAL SECURITY OR FEDERAL IDENTIFICATION NUMBER:

CONTACT INFORMATION

PRIMARY CONTACT PERSON:

TITLE:

PRIMARY CONTACT PERSON: _____________________________________ E-MAIL ADDRESS: ___________________________________

ADDRESS:

TELEPHONE NUMBER: (

)

CITY:

STATE:

ZIP CODE:

FINANCIAL INFORMATION

BANK NAME:

BANK PHONE NUMBER: (

)

Enter one numeric character in each of the

boxes below for Bank Account Number and

TYPE OF BANK ACCOUNT (Please specify):

SAVINGS

CHECKING

Routing Transit Number.

BANK ACCOUNT NUMBER:

ROUTING TRANSIT NUMBER:

AUTHORIZATION STATEMENT

I authorize the City of Cincinnati Finance Department to initiate ACH Debit entries to the financial institution account indicated above for payment of

withholding taxes owed to the Cincinnati Income Tax Bureau upon request by the Taxpayer or his/her representative. This authorization is to remain in effect

until the City of Cincinnati Finance Department has received written notification from the Taxpayer.

I hereby authorize the contact person listed on this form and the financial institutions involved in processing 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