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I (we) hereby authorize the Pulaski County Collector, hereinafter called COLLECTOR, to initiate debit entries to my (our) Checking Account/Savings Account (select one) indicated below at the depository financial institution named below, hereinafter called DEPOSITORY, and to debit the same to such account. I (we) acknowledge that the origination of APS transactions to my (our) account must comply with the provisions of U.S. Law. The taxpayer understands that failure to notify the COLLECTOR of any account changes which result in a payment not being honored by the financial institution may result in late penalty and interest charges for which the taxpayer will be responsible. By signing this authorization form, the taxpayer agrees to participate in the 2011 AUTOMATED PAYMENT SERVICE program as outlined in this payment agreement until further notice. (Voided Check is required)
Bank _________________________________________________________________________
City, State ZIP _________________________________________________________________
Routing#_______________________ Account#___________________ Account Type________
Please select the day you wish to have your account debited: 5th____ or 20th ____ of each month.
This authorization is to remain in full force and effect until the COLLECTOR has received written notification from me (or neither of us) of its termination, amendment, or suspension, no less than five working days before the due date as to afford COLLECTOR and DEPOSITORY a reasonable opportunity to act on it.
Name(s) _______________________________________________________________________
Mailing Address ________________________________________________________________
City, State & Zip Code ___________________________________________________________
Signature(s) ____________________________________________________________________
Your Daytime Phone Number _____________________________________________________
Email Address __________________________________________________________________
Account # _____________________________________________________________________
Note: There will be a total of 11 monthly payments based on the 2010 amount (2010 tax amount/s must be paid in full). The 11 payments will consist of 10 equal installments with the eleventh and final payment being the balance of the tax due. All payments are due by December 31st and that the failure to make a scheduled payment shall result in the termination of said payment plan.
_____________________________________________
Taxpayer Date
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