Form Eft-Pre - Electronic Funds Transfer (Eft) Authorization Agreement - 2013

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Fairfax County Department of Tax Administration (DTA)
FORM
ELECTRONIC FUNDS TRANSFER (EFT)
12000 Government Center Parkway, Suite 223
EFT-PRE
AUTHORIZATION AGREEMENT
Rev 10-2013
Fairfax, VA 22035
Phone: 703-222-8234; TTY: 703-222-7594
Fax: 703-324-3935;
R
E
/
P
P
T
FOR THE PAYMENT
EAL
STATE AND
OR
ERSONAL
ROPERTY
AXES
New EFT Authorization
Modify Existing EFT Authorization – Desired Change:
Update Information
Change Deduction Amount or Date
Add New Property
Delete Property
Name
Business Name (If Applicable)
Mailing Address
City
State
Zip Code
Home Phone
Business Phone
Cell Phone
E-mail
Name of Financial Institution
Name on Bank Account
Bank Account Type
Checking (Attach Voided Check)
Bank Account Number
Nine Digit Routing Transit Number
Savings (Attach Deposit Slip)
Real Estate Tax Payments
Please select the initiation date and frequency of the electronic debits for your real estate taxes (check one):
st
th
Monthly: 1
of each month
Monthly: 15
of each month
st
th
Quarterly: 1
of January, April, July and October
Quarterly: 15
of January, April, July and October
Lump Sum – full tax amount is deducted on the due date (please leave the Debit Amount blank):
 1
st
th
 2
nd
th
Installment: July 28
Installment: December 5
Please enter the property address and deduction amount for each property:
For DTA Use Only
Property Address
Debit Amount
Map Number
MTP
$
$
$
$
Personal Property Tax Payments
Please select the initiation date and frequency of the electronic debits for your personal property taxes (check one):
st
th
Monthly: 1
of each month
Monthly: 15
of each month
st
th
Quarterly: 1
of January, April, July and October
Quarterly: 15
of January, April, July and October
th
Lump Sum – full tax amount is deducted on October 5
(please leave the Debit Amount blank):
Please enter the year/make/model and deduction amount for each vehicle:
For DTA Use Only
Year/Make/Model
Debit Amount
Property Number
$
$
$
$
Funds will be debited from your bank account within two business days after the initiation date selected above. If the date selected falls on a
holiday or weekend, the transaction will be initiated the next business day. Payments will be credited using the initiation date. All taxes must be
paid in full on or before the due date. A bill will be sent before the due date for any tax not yet paid. Any outstanding balance after the due date
will accrue interest and penalty.
I certify that I have the authority to request an electronic funds withdrawal from the bank account identified above and I authorize Fairfax County,
through a third party processor, to initiate and process electronic funds withdrawals from the above account. This EFT authorization agreement
remains in effect until Fairfax County receives written notification from me of its termination. Cancellation of this EFT authorization agreement will
take effect within 30 days of receiving a termination letter.
My signature indicates that I understand and agree to the terms and conditions of this electronic funds transfer authorization
agreement.
Authorized Signature: _______________________________________________________
Date: __________________
Mail this form with voided check/deposit slip to: DTA, 12000 GOVERNMENT CENTER PKWY, SUITE 223, FAIRFAX, VA 22035

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