City of Lakewood 
                            Division of Municipal Income Tax 
                            12805 Detroit Avenue  Lakewood, OH 44107 
    Telephone: (216) 529-6620  Fax: (216) 529-6099 
                                      
                                   www.lakewoodoh.gov  
                                      
                                                                                Form ACH-Q 
                                                                                                   
 ACH Electronic Funds Transfer Registration Form – Quarterly Estimate 
                                      
Primary Name:______________________________________________________________________ 
 
Joint Name:_________________________________________________________________________ 
 
Mailing Address:____________________________________________________________________ 
 
City: ________________________     State: _________   Zip Code: _______________ 
 
Contact Phone # (including area code): _________________________ 
 
Email address:______________________________________________________________________ 
 
 Bank Information – AN ORIGINAL VOIDED CHECK MUST BE ENCLOSED 
 
Financial Institution: ______________________________________  Checking         or     Savings    
 
Account listed in the name(s) of:  
 
_____________________________________               Routing #: _____________________________ 
 
_____________________________________               Account#: _____________________________ 
 
Contact Phone #: (if different from above) _____________________________ 
 
I/we authorize the City of Lakewood – Division of Municipal Income Tax to instruct my/our banking 
institution to deduct via an ACH electronic fund transfer the predetermined quarterly estimates from 
                                                                              th
my/our listed account.  I/we understand that my/our account will debited on April 15  (if applicable), 
 th th                             th
June  15 ,  September 15 , and  January  15   of  the following year for the duration of the declared 
estimate.   In the event that the debit date falls on a weekend or holiday, I/we understand that the 
transfer will be done the next business day.  I/we understand that an ACH electronic fund transfer 
returned unpaid is considered Non-Sufficient Funds (NSF) and will be  assessed a $30 fee.   I/we 
understand if at any time I/we need to make changes, I/we 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