Ach Electronic Funds Transfer Registration Form - Payment Plans printable pdf download

ACH ELECTRONIC FUNDS TRANSFER REGISTRATION FORM – PAYMENT PLANS

New _____ Change Account ____ Change Banking Institution ____ Discontinue ____

Taxpayer Information:

Monthly Withdrawl $______________ Approval ___________

Primary Name: _____________________________ Social Security # ___________________

Joint Name: _______________________________ Social Security # ___________________

Mailing Address: _____________________________________________________________

City: __________________________________ State:__________ Zip Code +4: __________

Contact Phone # (including area code): ____________________________________________

Email Address: _______________________________________________________________

Bank Information – AN ORIGINAL VOIDED CHECK MUST BE ATTACHED

Financial Institution: ___________________________Checking

or Savings

Account listed in the name(s) of:

_______________________________________

Routing #: _________________________

_______________________________________

Account #: _________________________

Contact Phone # (if different then above): ____________________________

I/we authorize the City of Warren Income Tax Department to instruct my/our banking institution to deduct via an ACH

electronic fund transfer the predetermined payment plan amount for income tax due from my/our listed account. I/we

understand that my/our account will be debited on the 20th of each month for the duration of the payment plan. In the event

that the 20

falls on a weekend or holiday, I/we understand that the transfer will be done the next business day. I/we

understand that an ACH electronic fund transfer returned unpaid is considered Non-Sufficient Funds (NSF) and will be

assessed a $25 fee. I/we understand if at any time I/we need to make changes to the Automatic Payment Plan, I/we will

notify the City of Warren via form ACH – Change or telephone (330-841-2628) a minimum of five (5) days prior to the next

scheduled funds transfer.

Signature: _____________________________________________________ Date: ___________________

Mail or fax completed form to:

Warren Income Tax Department Fax: 330-841-2626

P.O. Box 230, Warren, Ohio 44482

Ach Electronic Funds Transfer Registration Form - Payment Plans