Authorization For Electronic Withdrawal Form - 2005 printable pdf download

Authorization For Electronic Withdrawal Form - 2005

ALBION 3120 (Rev.11/05)

Authorization for Electronic Withdrawal

Issued under P.A. of 1964 as amended.

Before making electronic payments for the City of Albion Taxes, you must grant us permission to access your

bank account to withdraw the funds you authorize. Please do this by signing below and returning this form.

You will also need to complete and return the CITY OF ALBION EFT APPLICATION FORM (Form 3117) and

the AUTHORIZED EFT SIGNATURE PAGE (Form 3121). When the City of Albion receives the completed

forms your Web-based account will be set up. A copy of form 3117 signed by a city representative will be

returned to you; upon receipt of the signed form you will be able to make your payments using this system.

I have given the City of Albion my business checking account number so that my business taxes, (withholding

and/or corporate) may be debited to that account. I understand that only the withdrawals I authorize by signing

on the Electronic Payment Web-site, will be made and that this process is protected by a password and user

code. Under these conditions, I grant the City of Albion permission to make the authorized withdrawals from my

account.

Print Name of Company

Federal ID Number

Printed Name of Authorized Representative

Signature of Authorized Representative

Date

Please return all forms to:

City of Albion

Income Tax Department

112 West Cass St

Albion, MI 49224-0900

Authorization For Electronic Withdrawal Form - 2005