Ach Electronic Funds Transfer Registration - City Of Hamilton Income Tax Division Form

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City of Hamilton Income Tax Division
345 High St, Ste 310 Hamilton, OH 45011
Telephone 513 785-7400
Toll Free 1-800-854-1684
Fax 513 785-7401
Email: citytax@hamilton-oh.gov
Web Site:
ACH ELECTRONIC FUNDS TRANSFER REGISTRATION FORM
Taxpayer Information
Acct #: ___________
Municipality: ______________
Fed ID/SS #: ________________
Company Name:_________________________________________________________________
Payroll Company (if applicable): ___________________________________________________
Contact Person/Title: _____________________________________________________________
Phone# & Ext: _________________________________________________________________
Contact Email: __________________________________________________________________
Address for correspondence: ______________________________________________________
______________________________________________________
______________________________________________________
Taxpayer’s Financial Institution Information
Financial Institution Name: _______________________________________________________
Financial Institution Add: _________________________________________________________
_________________________________________________________
Contact Phone# & Ext: ___________________________________________________________
Note: A separate form should be submitted for each municipality.
Do not combine payments for multiple municipalities on one payment, coupon or reconciliation.
Authorization Statement
I certify that I have the authority to register to submit payments using ACH Electronic Funds
Transfer on behalf of the taxpayer. I authorize the City of Hamilton to accept ACH Electronic
Funds Transfer payments. The City of Hamilton is to reach the Contact Person regarding
inquiries or discrepancies.
Authorization Signature
Date
Printed Name
Title

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