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;

FOR THE PAYMENT

EAL

STATE AND

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):

Monthly: 1

of each month

Monthly: 15

of each month

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

 2

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):

Monthly: 1

of each month

Monthly: 15

of each month

Quarterly: 1

of January, April, July and October

Quarterly: 15

of January, April, July and October

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