Form Eft-1 - Authorization Agreement For Electronic Funds Transfer For Real Estate And/or Personal Property Taxes
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1F
C
FORM
FORM
FORM
FORM
FORM
AIRFAX
OUNTY
EFT-1
D
T
A
EPARTMENT OF
AX
DMINISTRATION
A
UTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER
/
FOR REAL ESTATE AND
OR PERSONAL PROPERTY TAXES
V
: 703- 222-8234
F
: 703- 324-3935 TTY: 703- 222-7594
OICE
AX
I authorize Fairfax County, through Bank of America and Metavante, private firms, to start debiting my bank account as
specified below. If the date I select falls on a holiday or weekend, payment will be debited the next business day. Transfer of
funds to the County will not occur if there are insufficient funds in my account.
(Please print)
__________________________ First Name:__________________ Middle Name:_______________
Last Name:__
Social Security #:____________________ Mailing Address:______________________________________________________
City:_______________________________ State:_____ Zip:______________ E-mail:________________________________
Phone Number: (____)________________________
Home Phone Number: (_____)___________________
Business
Please choose one payment plan:
Monthly: 1st of each month
Monthly: 15th of each month
Quarterly: 1st of each month; January, April, July and Oct.
Quarterly: 15th of each month; January, April, July and Oct.
Semi-annually for real estate taxes: 1st of May, October
Semi-annually for real estate taxes: 15th of May, October
Semi-annually for personal property taxes: 1st of February and August
Semi-annually for personal property taxes: 15th of February and August
Lump Sum: 1st of month prior to tax due date
Lump Sum: 15th of month prior to tax due date
Bank Name:_______________________________________ Bank Account Number:________________________________
Bank Account in the name of: ______________________________
Account type: Savings
Checking
Bank Routing Number (nine digits):____________________________
Real Estate Taxes
Office use only
MTP
Map Number
Property Address
Amount per Debit
Personal Property Taxes
Office Use Only
Property Number
Year/Make/Model
Amount per Debit
This authorization is to remain in effect until Fairfax County receives written notification from me of its termination. Cancella-
tion of this authorization will take effect within 30 days of receiving a termination letter.
All taxes have to be paid in full on or before the due date. We will bill you before the due date for any tax not yet paid. Any
outstanding balance after the due date will accrue interest and penalty.
I have read and agree to the terms and conditions contained on this form:
Signature:___________________________________ Date:___________
P P P P P
LEASE
LEASE ENCLOSE
LEASE
ENCLOSE
ENCLOSE
ENCLOSE COPY
COPY
COPY
COPY OF
OF
OF
OF VOIDED
VOIDED
VOIDED
VOIDED CHECK
CHECK
CHECK
CHECK FOR
FOR
FOR CHECKING
FOR
CHECKING
CHECKING
CHECKING ACCOUNT
ACCOUNT
ACCOUNT DEDUCTIONS
ACCOUNT
DEDUCTIONS
DEDUCTIONS
DEDUCTIONS OR
OR
OR
OR DEPOSIT
DEPOSIT
DEPOSIT
DEPOSIT SLIP
SLIP
SLIP
SLIP
LEASE
LEASE
ENCLOSE
COPY
OF
VOIDED
CHECK
FOR
CHECKING
ACCOUNT
DEDUCTIONS
OR
DEPOSIT
SLIP
. . . . .
FOR
FOR
FOR
FOR
FOR SA
SA
SA
SA
SAVINGS
VINGS
VINGS
VINGS
VINGS A A A A A CCOUNTS
CCOUNTS
CCOUNTS
CCOUNTS
CCOUNTS DEDUCTIONS
DEDUCTIONS
DEDUCTIONS
DEDUCTIONS
DEDUCTIONS IN
IN
IN
IN
IN THE
THE
THE
THE ENVEL
THE
ENVEL
ENVEL
ENVEL
ENVELOPE
OPE
OPE
OPE
OPE PR
PR
PR
PR
PRO O O O O VIDED
VIDED
VIDED
VIDED
VIDED
03/02
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Parent category: Financial