County Clerk Personal Check Form
Date:
To: Denton County Clerk, Juli Luke Department: Recording
From Name: ________________________________ Firm:_____________________________________
Phone #: ( ) ______-_______
Personal Check: (*-information required)
*First Name: ________________________________ *Last Name: ________________________________
*Mailing Address: __________________________________ *City ________*State______ *ZIP_________
*
Daytime Phone# ( )
______-_______
*Driver’s License # _________________________ *Issuing State ________ *Date of Birth ____/_____/___
*Routing #. ______________________ *Account # ____________________ *Check # _________________
Email Address___________________________________________________________________________
Providing an email address will allow your receipt to be emailed to you.
Authorized Signature: ______________________________________________________
This form author
izes the Merchant (VitalChek) to charge my account, for services rendered by the County Clerk’s Office plus a $2.50 service
fee. Also authorizing the Merchant to convert their check to an Electronic Funds Transfer or Paper Draft, and to debit their account for the total
transaction amount. In the event that the draft or EFT is returned unpaid, the Customer agrees that a fee of $25.00 or as allowable by law may be
charged to their account via draft or EFT. Please see our website for additional fees. www.dentoncounty.com/ccl
Please list all documents:
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signature
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