Authorization Agreement For Automatic Debit
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Authorization Agreement For Automatic Debit Form. This is a Ohio form and can be use in Licking County (Court Of Common Pleas).
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Tags: Authorization Agreement For Automatic Debit, Ohio County (Court Of Common Pleas), Licking
MICHAEL L. SMITH
Licking County Treasurer
Donald D. Hill Administration Building
20 South Second Street
P.O. Box 830
Newark, OH 43058-0830
AUTHORIZATION AGREEMENT FOR AUTOMATIC DEBIT
(ACH Debits)
Please complete ALL sections:
(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):
Phone:
Address:
City:
State:
Signature:
Zip:
Date:
Account Information:(Bank, Savings & Loan, Credit Union)
Real Estate Parcel(s) Information:
Enter the Routing Number, Account Number, and Financial
Institution name from your check or share draft below:
Parcel No.:
Address of Property:
Parcel No.:
Address of Property:
Routing Number:
Account Number:
Financial Institute:
IMPORTANT!! Please attach a voided check for the
account you wish to debit your payments
***use back of form to list additional parcels***
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
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