Louisville Metro Revenue Commission 

          Electronic Funds Transfer 
                                                                                         ACH_2018_V1.1D      Form 
          Agreement (ACH Credit)                                                                                  ACH
Submission  Reason for Submission: 
            
Questions     New ACH Credit Authorization          Revision to current                ACH Termination Request
                                                     Authorization (i.e. account or
                                                     bank changes)
            Check applicable box: 
             Taxpayer                                                   Payroll Service Provider
General     Legal name/ Business name                                                  Federal ID Number 
Information 
            Address (street and number)                                                           Unit/Apt no. 

            City, town, or post office                       State                                Zip Code 

            EFT Contact Person                               EFT Contact Email 

            Phone no.                         Ext.   Fax no.                           Revenue Commission Account ID 

            Financial Institution 

Agreement   The Louisville Metro Revenue Commission is hereby requested to grant approval to the above named business 
            to initiate Automated Clearing House credit transactions to the bank account of the Louisville Metro Revenue 
            Commission. These payments must be in the National Automated Clearing House Association (NACHA) CCD+ 
            format using the Tax Payment Convention (TXP). I understand that the above named business is responsible 
            for paying the cost of initiating such transactions that may be charged by the business’ financial institution. I 
            acknowledge that the origination of ACH transaction to my account must comply with the provisions of U.S. 
            law. I, along with the Louisville Metro Revenue Commission, agree to abide by all applicable ACH operating 
            rules in effect. A confirmation letter will be e-mailed to the designated EFT Contact Person detailing the 
            Louisville Metro Revenue Commission’s routing number and designated bank account number. Any 
            transmission errors are the responsibility of the taxpayer and their bank. 

            This agreement is to remain in full force and effect until the Louisville Metro Revenue Commission has 
            received written notification from me of its termination so as to afford the interested parties a reasonable 
            time to act on it. 
Signature   Authorized Signature                                                         Title 

            Print Name                                                                   Date 

                        MAILING ADDRESS: P.O. BOX 32060, LOUISVILLE, KENTUCKY 40232-2060 
                                              Telephone: (502) 574-4860