ACH Authorization Form

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

Name

Mailing Address

This authorization is for

Tax PaymentUtility Payment

Utility Account Numberif applicable

Block

Lot

Qualification

Name of Bank

Bank Account Number

Type of Account

Checking AccountSavings Account

ABA Routing 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 OPPORUNITY TO ACT ON IT. I (WE) UNDERSTAND THAT MY (OUR) BANK WILL BE DEBITED ON THE 25TH OF THE MONTH PRECEDING THE DUE DATE FOR TAX DEBITS OR ON THE 15TH OF THE MONTH DUE FOR UTILITY (WATER/SEWER) DEBITS.

E SignaturePlease type your full name.

Phone Number

Email Address

Copy of Voided Check

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.

Municipal Center Address: 49 Union Street, Medford, NJ 08055-2432
Phone: (609) 654-2608
Fax: (609) 953-4087
Hours: 8:30 am - 4:30pm

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ACH Authorization Form

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