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

                                                                              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 December 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