City of Brook Park – ACH Debit Transmission Form 
 
The Tax Department uses the Tax Connect payment system. (Electronic Funds Transfer is 
mandatory pursuant to Ordinance 1713.02(g)).  The Tax Connect ACH Debit system processes 
data entered through the City of Brook Park’s website www.cityofbrookpark.com.  
 
For new businesses, the form below must be completed and returned to the tax department 
via regular mail 6161 Engle Road, Brook Park, OH  44142 or facsimile @ 216-433-0822. 
 
TRANSMISSION FORM         PLEASE PRINT LEGIBLE  ATTACH VOIDED CHECK 
 
CITY OF BROOK PARK TAX ACCOUNT NUMBER                                                                                     
(If a new business please submit this form along with your registration form and you will be assigned an account number) 
 
1.) Company Name:                                                                                                              
Address:                                                                                                                   
                                                                                                                           
2.) Financial Institution Name:                                                                                            
3.) Financial Institution’s ABA/Routing Number:                                                                            
4). Bank Account Number:                                                                                                   
Contact Person:                                                                                                            
                                   (Please Print) 
                                    
Phone Number:                         Fax Number:                                                                         
 
Signature: ____________________________________________Date: _____________________ 
 
Information provided on this form is confidential and used for City Income Tax purposes only. 
 
NOTE: Failure to remit by electronic funds transfer or for electronic transactions returned for 
incorrect banking information will subject taxpayer to penalty assessment.  
Courtesy withholders contact Tax Department directly for any document requests. 
 
*******Tax Connect ACH-Debit Operating Instructions are available on our website*******