ACH CREDIT ELECTRONIC FILING PROGRAM 
                       Authorization Form for Electronic Funds Transfer 
                                              
                                          Taxpayer Information 
  
 Company Name:                                                           
Federal ID or Soc Sec #:                                                 
City Being Filed:                                                                         
 Account Number:                                                         
Name & Address of                                                        
 Banking Institution:                      
                                                                         
                                           Contact Information 
  
Primary Contact Person:                                                  
Address:                                                                 
                                                                         
Direct Phone Number & Ext:                                               
E-Mail Address                                                           

                                          Authorization Statement 
  
 I hereby authorize the contact person listed on this form and the financial institutions involved in 
 processing of my payments to receive confidential information necessary to effect electronic 
 payment of withholding taxes, answer inquiries, and resolve issues related to enrollment and 
 payments.  If signed by a corporate officer, partner or fiduciary on behalf of the taxpayer, I certify I 
 have the authority to execute this authorization on behalf of the taxpayer.  This authorization is to 
 remain in full force until the City of Parma Income Tax Division has received written notification 
 from me of termination in such time as to afford a reasonable opportunity to act on it. 
  
 Taxpayer Signature                            Date 
  
 Printed Name                                  Title 
 Mail the completed registration form to: 
                       ACH CREDIT ELECTRONIC FILING PROGRAM 
                           City of Parma Income Tax Department 
                                           6611 Ridge Road 
                                           Parma, Ohio 44129 
    Account specifications will be mailed to you once your registration form has been accepted 

                                                                        REVISED 5-16-2016 
                                                                  (2) ACH ENROLLMENT FORM .doc