Cca Form 120-16-Ir - City Tax Form - Cleveland - 2013 Page 2
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MAIL
Central Collection Agency
Central Collection Agency
Central Collection Agency
TO
PO BOX 94723
PO BOX 94810
PO BOX 94520
Cleveland OH 44101-4723
Cleveland OH 44101-4810
Cleveland OH 44101-4520
DETACH HERE
CREDIT CARD AUTHORIZATION
CCA-MUNICIPAL INCOME TAX
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
ACCOUNT NUMBER
TOTAL AMOUNT CHARGED $
EXPIRATION DATE
V CODE
/
/
CARDHOLDERS AUTHORIZED SIGNATURE
DATE
MO.
YR.
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