Authorization Form For Direct Payment
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1Authorization for Direct Payment of Fillmore County Property Tax
Tax Property Information: (Please Print)
Taxpayer’s Name(s):_____________________________________
R.__ __. ___ ___ ___ ___ . ___ ___ ___
9 Digit properties ID Number:
R.__ __. ___ ___ ___ ___ . ___ ___ ___
9 Digit properties ID Number:
R.__ __. ___ ___ ___ ___ . ___ ___ ___
9 Digit properties ID Number:
R.__ __. ___ ___ ___ ___ . ___ ___ ___
9 Digit properties ID Number:
R.__ __. ___ ___ ___ ___ . ___ ___ ___
9 Digit properties ID Number:
R.__ __. ___ ___ ___ ___ . ___ ___ ___
9 Digit properties ID Number:
(Please include a listing of all parcels to be included in this authorization. Use back of form if you have mare parcels to
include).
Taxpayer’s Address
__________________________________________________________
Taxpayer’s Mailing Address ___________________________________________________________
Taxpayer’s City
____________________________ State ______________ Zip____________________________
Daytime Phone Number: __________________________________________________
Home Phone Number:
___________________________________________________
Email Address (optional): ____________________________________________________________________________________
Financial InstitutionName: ____________________________________________________________________________________
Type of Account, please check one:
_____________Checking
_________Savings
Bank Routing Number: ________________________________ Account Number: _____________________________________
**Include a voided check to verify the routing and account number.
I hereby authorize Fillmore County Auditor/Treasurer to automatically withdraw from the above named
. The automatic
account for payment of real estate taxes for the parcel described above
payment will be for the amount of property taxes due on the date they
are due according to the parcel’s property tax statement.
Payments will be
th
th
th
automatically paid on May 15
, October 15
, or November 15
. This authorization is to remain in effect
until the Fillmore County Auditor/Treasurer has received written notification to terminate or change this
authorization by adding parcels, deleting parcels, changing financial institutions or Fillmore County
requires termination and I am notified. I understand that failure to have sufficient funds on the date of debit
will result in inability to remain in the program. I also agree to notify the Fillmore County
Auditor/Treasurer of any change in this authorization at least 2 weeks prior to the debit date on my tax
statement to request a change in plan participation. I have also read the Fillmore County ACH Policy
and Procedure document and been provided a copy of that document. I agree to all of the terms of
that policy and procedures documented.
Signature: _____________________________________ Date: ______________________
Signature: _____________________________________ Date: ______________________
Return form to: Fillmore County Auditor/Treasurer, P.O. Box 627, Preston, MN 55965
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