BUILDING INSPECTION DEPARTMENT
970.668.3170 ph | 970.668.4255 f 0037 Peak One Dr. | PO Box 5660
www.SummitCountyCO.gov Frisco, CO 80443
Credit Card/eCheck Authorization Form
Sign and complete this form to authorize Summit County Government to make a one-time charge to your credit
card or payment with an eCheck listed below.
By signing this form, you give Summit County Government permission to debit your account for the amount
indicated on or after the authorization date. This is permission for a single transaction only, and does not
provide authorization for any additional unrelated debits or credits to your account.
I _______________________ authorize Summit County Government to charge my
(Cardholder’s Full Name)
credit card account indicated below for technical permit or window permit fees.
This payment is for ________________________________.
(Site Address)
Billing Information
Phone # ______________________ Email ________________________
Card Details (Please note Credit Card Fee 75 cents plus 2.25%)
☐ Visa ☐ MasterCard ☐ Discover ☐ American Express
Cardholder Name ___________________________
Account/CC Number ___________________________
Expiration Date ____ /____
CVV ____
Banking Information for eCheck Payment ($1 fee)
Name on Account_________________________
Routing Number__________________________
Account Number__________________________ Checking Savings
I authorize Summit County Government to withdraw from account indicated in this authorization form according
to the terms outlined above. This payment authorization is for the goods/services described above, for the
amount indicated above only, and is valid for one (1) time use only. I certify that I am an authorized user of this
credit card and that I will not dispute the payment with my credit card company; so long as the transaction
corresponds to the terms indicated in this form.
SIGNATURE ___________________________ DATE ________________
Please send authorization form via secure email or fax (970) 668-4255
