City of Lakewood
                                  Division of Municipal Income Tax
                                  12805 Detroit Ave.
                                  Lakewood, OH  44107

  Telephone:   (216) 529-6620  Fax:  (216) 529-6099
                                  www.onelakewood.com

Tax ID #: ___________________                                                 Form ACH-P

  ACH Electronic Funds Transfer Registration Form – Payment Plans

Primary Name: ________________________________________________________________

Joint Name: __________________________________________________________________

Mailing Address: ______________________________________________________________

City: ________________________   State: _________  Zip Code: _______________

Contact Phone #: _________________________

Email address:________________________________________________________________

Bank Information – PLEASE INCLUDE AN ORIGINAL VOIDED CHECK IF AVAILABLE

Financial Institution: ____________________________  Checking □ or  Savings □

Account listed in the name(s) of:
________________________________             Routing #: ______________________

________________________________             Account #: ______________________

Contact Phone #: (if different from above) ___________________________

I/we authorize the following ACH Electronic Fund Transfer amount and withdrawal start-up month:

Monthly Payment Amount: $____________                Withdrawal Date: __________ 22, 20___

I authorize the City of Lakewood – Division of Municipal Income Tax to instruct my banking institution to deduct via an
ACH electronic fund transfer the predetermined payment plan amount for income tax due from my listed account.  I
                                          nd
understand that my account will be debited on the 22 of each month for the duration of the payment plan.  In the
nd
event that the 22 falls on a weekend or holiday, I understand that the transfer will be done the next business day.  I
understand that an ACH electronic fund transfer returned unpaid is considered Non-Sufficient Funds (NSF) and will be
assessed a $30 fee.  I understand if at any time I need to make changes to the Automatic Payment Plan, I will notify the
City of Lakewood – Division of Municipal Income Tax via Form ACH-C or telephone a minimum of five (5) days prior to
the next scheduled funds transfer.

Signature:____________________________________________  Date: ____________

Signature: ____________________________________________ Date: ____________

Mail completed form to the above Lakewood address or fax to: 216-529-6099