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Authorization Agreement For Automatic Debit - Ohio
| Authorization Agreement For Automatic Debit Form. This is a Ohio form and can be used in Treasurers Office Licking County (Court Of Common Pleas) . |
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Licking County Treasurer Donald D. Hill Administration Building 20 South Second Street Please complete ALL sections: MICHAEL L. SMITH P.O. Box 830 (ACH Debits) Newark, OH 43058-0830 AUTHORIZATION AGREEMENT FOR AUTOMATIC DEBIT (PLEASE ALLOW 6 - 8 WEEKS) I hereby authorize the Licking County Treasurer's Office to instruct my banking/savings institution to make my real estate tax payments from the account listed below. I understand that I control my payments, and if at any time I decide to discontinue this payment service, I will notify the Licking County Treasurer's Office in writing allowing reasonable opportunity to act on such request (4 weeks). (PLEASE PRINT) Name (as shown on bill): Address: City: Signature: Account Information:(Bank, Savings & Loan, Credit Union) Enter the Routing Number, Account Number, and Financial Institution name from your check or share draft below: Routing Number: Account Number: Financial Institute: Phone: State: Date: Real Estate Parcel(s) Information: Parcel No.: Address of Property: Parcel No.: Address of Property: ***use back of form to list additional parcels*** Zip: IMPORTANT!! Please attach a voided check for the account you wish to debit your payments IMPORTANT!! 1st half payment will be debited on February 5 -- 2nd half on July 5 Please call the Treasurer's Office (740) 349-6046 if you have any questions Return completed form to: Licking County Treasurer's Office, P.O. Box 830, Newark, OH 43058-0830 American LegalNet, Inc. www.USCourtForms.com
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