Request For Allocation Of Payments
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110107 Brecksville Rd. ● Brecksville, Ohio 44141-3275
1-800-860-7482 440/526-0900 Fax: 440/526-8813 TDD 440/526-5332
Request for Allocation of Payments
Primary Account
Social Security #
Secondary Account
Social Security #
Total amount of Estimated Tax payment & Tax Year that payments are to be transferred from
*$
Tax Year
Application of Allocated Funds
Name
Social Security #
Amount to be applied
Apply to Tax Year
Date of Move
Street Address (include Apt#/Suite)
City, State & Zip Code
Name
Social Security #
Amount to be applied
Apply to Tax Year
Date of Move
Street Address (include Apt#/Suite)
City, State & Zip Code
Total $
*must equal above total
Signature of Primary Filer
Date
Phone #
Signature of Secondary Filer
Date
Phone #
Note: Form must be signed and dated by both parties to be valid
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Parent category: Financial