Form Ach-C - Ach Electronic Funds Transfer Change Form printable pdf download

City of Lakewood

Division of Municipal Income Tax

12805 Detroit Avenue Lakewood, OH 44107

Telephone: (216) 529-6620 Fax: (216) 529-6099

Form ACH-C

File # ___________

Start Date ____________

ACH Electronic Funds Transfer Change Form

Payment Plan Change

Quarterly Estimate Change

Primary Name:______________________________________________________________________

Joint Name:_________________________________________________________________________

Mailing Address:____________________________________________________________________

City: ________________________ State: _________ Zip Code: _______________

Contact Phone # (including area code): _________________________

Email address:______________________________________________________________________

Bank Information – AN ORIGINAL VOIDED CHECK MUST BE ENCLOSED

Financial Institution: ______________________________________ Checking

Savings

Account listed in the name(s) of:

_____________________________________

Routing #: _____________________________

_____________________________________

Account#: _____________________________

Contact Phone #: (if different from above) _____________________________

Predetermined ACH Electronic Fund Transfer Amount

I/we authorize the following change to the predetermined ACH Electronic Fund Transfer Amount:

Payment Plan: $__________ per month

Quarterly Estimate: $_____________ per quarter

I/we authorize the City of Lakewood – Division of Municipal Income Tax to instruct my/our banking institution

to deduct via an ACH electronic fund transfer the predetermined payment plan or quarterly estimate amount for

income tax due from my/our listed account.

I/we understand that my/our account will debited on the

predetermined date for the duration of the payment plan or estimate. In the event that date 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 $30

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 Lakewood – Division of Municipal Income Tax via Form ACH - C or telephone a minimum of five

(5) days prior to the next scheduled funds transfer.

Signature:_________________________________________________________________________ Date: ____________

Signature: _________________________________________________________________________ Date: ____________

Mail completed form to the above Lakewood address or fax to: 216-529-6099

Form Ach-C - Ach Electronic Funds Transfer Change Form