REVISED 5-16-2016
(2) ACH ENROLLMENT FORM .doc
ACH CREDIT ELECTRONIC FILING PROGRAM
Authorization Form for Electronic Funds Transfer
Taxpayer Information
Company Name:
Federal ID or Soc Sec #:
City Being Filed:
Account Number:
Name & Address of
Banking Institution:
Contact Information
Primary Contact Person:
Address:
Direct Phone Number & Ext:
E-Mail Address
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 Parma 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 Parma Income Tax Department
6611 Ridge Road
Parma, Ohio 44129
Account specifications will be mailed to you once your registration form has been accepted
click to sign
signature
click to edit
![]()
