I (we) authorize Medford Township to initiate debit entries to my account indicated below.

NAME: ______________________________________________________________

MAILING ADDRESS ____________________________________________________

This authorization is for: (check one)

TAX PAYMENT_______________ UTILITY PAYMENT________________

UTILITY ACCOUNT NUMBER (if applicable)_________________________________

BLOCK __________________LOT_______________ Qualification ________________

NAME OF BANK: _______________________________________________________

BANK ACCOUNT NUMBER: _____________________________________________

Is this a Checking Account? __________ or Savings Account?

ABA ROUTING TRANSIT NUMBER _________________________________________

THIS AUTHORIZATION IS TO REMAIN IN FULL FORCE AND EFFECT UNTIL MEDFORD TOWNSHIP HAS RECEIVED WRITTEN NOTIFICATION FROM ME ( US ) OF ITS TERMINATION IN SUCH TIME AND IN SUCH MANNER AS TO AFFORD MEDFORD TOWNSHIP A REASONABLE OPPORTUNITY TO ACT ON IT. I (WE) UNDERSTAND THAT MY (OUR) BANK ACCOUNT WILL BE DEBITED ON THE 25TH OF THE MONTH PRECEEDING THE DUE DATE FOR TAX DEBITS OR ON THE 15TH OF THE MONTH DUE FOR UTILITY (WATER/SEWER) DEBITS.

(_____)________________________
Authorized Signature Daytime Phone #

_________________________________________ (_____)_________________________
Authorized Signature (Joint Account) Evening or Cell Phone #

EMAIL ADDRESS ____________________________________

PLEASE NOTE THAT WE CANNOT PROCESS THIS REQUEST UNLESS YOUR VOIDED CHECK IS ATTACHED. A DEPOSIT SLIP MAY BE USED ONLY IF THIS IS A SAVINGS ACCOUNT FOR WHICH YOU HAVE NO CHECKS. PLEASE MAIL COMPLETED FORM TO:

Township of Medford
Office of the Tax Collector
17 North Main Street
Medford , NJ 08055