City of Lakewood
                                      Division of Municipal Income Tax
                                    12805 Detroit Avenue  Lakewood, OH 44107
                                 Telephone: (216) 529-6620  Fax: (216) 529-6099
                       Website: www.onelakewood.com Email: taxdept@lakewoodoh.net

Tax ID #: ______________                                                         Form ACH-C

                     ACH Electronic Funds Transfer Change Form

Payment Plan Change                                            Quarterly Estimate Change      

Primary Name:______________________________________________________________________

Joint Name:_________________________________________________________________________

Mailing Address:____________________________________________________________________

City: ________________________   State: _________  Zip Code: _______________

Contact Phone # (including area code): _________________________

Email address:______________________________________________________________________

Bank Information–PLEASE INCLUDE A VOIDED CHECK IF AVAILABLE

Financial Institution: ______________________________________   Checking      or      Savings 

Account listed in the name(s) of:
_____________________________________               Routing #: _____________________________

_____________________________________               Account#: _____________________________

Contact Phone #: (if different from above) _____________________________

                     Payment Plan/Quarterly Estimate Withdrawal Amount

To raise or lower your predetermined ACH automatic withdrawal amount, please contact our office at
                                      (216) 529-6620.

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 payment plan or quarterly estimate amount for
income  tax  due  from  my/our  listed  account.    I/we  understand  that  my/our  account  will  debited  on  the
predetermined date for the duration of the payment plan or estimate.  In the event that 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 to the Automatic Payment Plan, 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