AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS)
Town of CharlestownAUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS (ACH DEBITS)Taxpayer InformationNames(s) _____________________________________________________________________________Address ______________________________________________________________________________City _____________________________________________________________State ____Zip ____Email Address _________________________________________________________________________Phone Number _________________________________________________________________________Account Number____________________Real Property Taxes ____________________Account Number____________________Motor Vehicle Taxes ____________________Account Number____________________Tangible Taxes ____________________Bank Account InformationI (we) acknowledge that the origination of (ACH) transactions to my (our) account must comply with the provisions of U.S. law.Bank Name ____________________________________________________________________________Bank Address __________________________________________________________________________Bank City _________________________________________________________State ____Zip _____Routing # (9 Digits) _____________________________Account # _____________________________Account Type:Checking _____Savings _____ (please check one)For payments from a Checking Account, this form MUST be accompanied by a Printed Voided Check.OR if from a Savings Account, this form MUST be accompanied by an Encoded Deposit Slip and written verification of routing number from the Bank. I (we) hereby authorize the Town of Charlestown, hereinafter called Company, to initiate debit entries to my (our) Account indicated above at the depository financial institution named above, hereafter called DEPOSITORY, and to debit the same to such account for payment of taxes:Frequency of payments:_____Weekly_____Bi-Weekly_____Monthly_____Quarterly_____AnnuallyACH Quarterly Payment Dates:1st Qtr Due Aug. 1st2nd Qtr Due November 1st3rd Qtr Due February 1st4th Qtr Due May 1stThis authorization is to remain in full force and effect until (Company) has received written notification from me (or either of us) of its termination in such time and in such manner as to afford (Company) and Depository a reasonable opportunity to act on it.______________________________________________________________________________________Taxpayer SignatureDate______________________________________________________________________________________Print NameNOTE: DEBIT AUTHORIZATIONS MUST PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION ONLY BY NOTIFYING THE ORIGINATOR IN THE MANNER SPECIFIED IN THE AUTHORIZATION. ................
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