INCOME TAX  DIVISION
                                                                                                            P.O. Box 293100
                                                                     Kettering, Ohio 45429-9100
                                                                     Phone:  (937) 296-2502
                                                                     Fax:  (937) 296-3242
                                                                     www.ketteringoh.org/tax

                   City of Kettering – Income Tax Division

                   ACH CREDIT ELECTRONIC FILING PROGRAM
                   Authorization Form for Electronic Funds Transfer

TAXPAYER INFORMATION

Taxpayer Account Name: _________________________________________________________________________________

Tax Account Number: __________________________________________________________________________________
SSN or FED TAX ID Number: _____________________________________________________________________________

Name of Financial Institution You Will Be Using for ACH Transactions:

_________________________________________________________________________________________________________

CONTACT INFORMATION

Primary Contact Person: __________________________________________________________________________________
Address: _________________________________________________________________________________________________

__________________________________________________________________________________________________________

Phone Number: __________________________________________________________________________________________

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 Kettering 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 KETTERING INCOME TAX DIVISION
                    P. O. BOX 293100
                    KETTERING, OH 45429-9100

             File layout specifications will be mailed to you once your registration form has been accepted.

                                                                      INCOME TAX  DIVISION
                                                                                          P.O. Box 293100
                                                                      Kettering, Ohio 45429-9100
                                                                           Phone:  (937) 296-2502
                                                                           Fax:  (937) 296-3242
                                                                      www.ketteringoh.org/tax

The City of Kettering is pleased to offer the ACH Credit Electronic Filing Program for remitting your
employee withholding tax payments. We are working to provide you with more efficient electronic tax
filing and reporting capabilities. Your participation in this new program will be greatly appreciated and we
look forward to working with you.

BENEFITS TO YOU

1) The ACH Credit Program is available to you 24 hours a day/7 days a week.
2) Your payments are processed conveniently and accurately via electronic funds transfer.
3) After you have registered for our program, no monthly or quarterly mailings are required.

REQUIREMENTS

To file using the ACH Credit Program, please contact your bank to ensure they can process ACH credit
transactions. If your bank does offer this service, ask for their ACH transmission schedule. This schedule
will determine the timing of when your payment should be credited.

ENROLLMENT

To register for the ACH Credit Electronic Filing Program, all you need to do is complete and return the
enclosed ACH Credit Authorization Form. Simply mail the form to us at:

               ACH CREDIT ELECTRONIC FILING PROGRAM
               CITY OF KETTERING INCOME TAX DIVISION
               P. O. BOX 293100
               KETTERING, OH 45429-9100

Once we receive your registration, we will send to you the file layout specifications
          that you will need to use for preparation of your ACH Credit file transmissions.