Cca Form 120-16-Ir - Municipal Income Tax - 2009 Page 3

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CREDIT CARD AUTHORIZATION
CCA-MUNICIPAL INCOME TAX
2009
205 W SAINT CLAIR AVE
CLEVELAND OH 44113-1503
TO CHARGE YOUR INCOME TAX DUE YOU MUST COMPLETE THE FOLLOWING:
CHECK ONE
VISA
MASTERCARD
DISCOVER
AMERICAN EXPRESS
Taxpayer Name
Taxpayer’s Social Security No.
–
–
Cardholder’s name
Cardholder’s address
Apt. #
City
State
Zip
V CODE
EXPIRATION DATE
ACCOUNT NUMBER
(Refer to Back of Card)
MO.
YR.
/
/
TOTAL AMOUNT CHARGED $
CARDHOLDERS AUTHORIZED SIGNATURE
DATE

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