Authorization Agreement Form For Pre-Authorized Income Tax Payments - City Of Delaware Income Tax Department

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CITY OF DELAWARE INCOME TAX DEPARTMENT
CITY OF DELAWARE INCOME TAX DEPARTMENT
CITY OF DELAWARE INCOME TAX DEPARTMENT
Dear Income Tax Customer,
For your convenience, the City of Delaware Income Tax Department offers free automatic electronic payment of your city
income taxes. If you have questions, please call the Tax Department at the number below.
How it works:
• Contact the Income Tax Department to determine your payment schedule. (Payments will be deducted on the 25th of each
month or the next working day if the 25th falls on a holiday or weekend.)
• Choose your checking or savings account.
• Contact your financial institution to see if it is active in the Automated Clearing House network (ACH.) Most major banking
institutions and many credit unions participate.
• Complete the application below.
• Attach a voided check if you are using a checking account.
• Mail, email, fax, or drop off the completed application to the Income Tax Department in City Hall.
City of Delaware Income Tax Dept.
PO Box 496
Delaware, OH 43015
IncomeTax@DelawareOhio.net
AUTHORIZATION AGREEMENT FOR PRE-AUTHORIZED INCOME TAX PAYMENTS
(Please print legibly.)
I/We hereby authorize the City of Delaware to initiate debit/credit entries to my/our bank account indicated below and the
financial institution named below to debit/credit the same to such account.
Depository Bank Name: __________________________________________________
City: __________________________ State: ______________ Zip: ______________
Transit/Routing/ABA # ______________________ Account # ___________________
□
□
Type of account:
Checking (Attach a voided check.)
Savings
□
□
I/We authorize $ _________________ to be debited
quarterly
monthly.
This authority is to remain in full force and effect until the City of Delaware and depository bank have received written
notification from me (or either of us) of its termination in such time and in such manner as to afford the City of Delaware and
depository a reasonable opportunity to act.
Name(s): ________________________________________________________ Delaware Income Tax ID # _______________
(please print clearly)
Signature: _____________________________________________________________ Date: ___________________________
Email address: __________________________________________________________
CITY OF DELAWARE INCOME TAX DEPARTMENT
1 S SANDUSKY ST / P.O. BOX 496
DELAWARE, OH 43015
740-203-1225 / FAX: 740-203-1249 /

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