Individual Tax Form Instruction Booklet - City Of Cleveland, Ohio Municipal Income Tax - 2006 Page 11

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VISA / MASTERCARD / DISCOVER PAYMENT AUTHORIZATION
2006
TO CHARGE YOUR INCOME TAX DUE TO YOUR VISA, MASTERCARD OR DISCOVER YOU MUST COMPLETE THE FOLLOWING:
CHECK ONE
VISA
MASTERCARD
DISCOVER
Taxpayer Name
Social Security No.
–
–
Name of spouse if joint return
–
–
Current 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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