nm3clol-public/Russell_County/Treasurers_Office/Treasurer-PPD_Recurring_Debits_Authorization

type	title	file	tags	docDate	contentType	contentLength	sha256sum	sha1sum
document	Treasurer-PPD Recurring Debits Authorization	../Treasurer-PPD_Recurring_Debits_Authorization.pdf	Russell_County Treasurers_Office	null	application/pdf	35008	3283995c0fd91aa856c1d61c89ccbdea5ba5a131d9bba70d9212288ed8117c87	9e3acfea393f748b9ed980b6b0d519cb5dbfb79a

PPD RECURRING DEBITS AUTHORIZATION

NAME: CONTACT #

WITHDRAWAL START DATE: 8", 15°, oF 30" of the month} WITHDRAWAL AMOUNT: $

‘TYPE OF TAXES AMOUNT TO REMOVED FOR: (PLEASE SELECT ALL THAT APPLY)

Personal Property Account #. Real Estate ‘Account # Both

| (we) hereby authorize Russell County Treasurer's Office hereinafter called the COMPANY, to initiate debt entries to my (our) (PLEASE SELECT ONE) Checking Savings Account

incicated below at the depositor financial institution named below, hereafter called DEPOSITORY, and to debit or credit the same to such account. If this tem is returned unpaid, | authorize an additional returned chéck fee ofthe maximum account as allowed by the state ta be charged to this account.

Depository Name: Routing Number: ‘Acoount Number:

‘Same amount to be debited each biling period.

(Or, | approve varying amounts between a range of $and $ ‘Number of Payments, or Indafinitely (check here). Frequency of Payments: (PLEASE SELECT ONE) __ Monthly Weekly

‘This authorization isto remain in fll force and effect for the number of payments authorized above or until the COMPANY and DEPOSITORY reasonable opportunity to act on it

Name: De Date:

Signature: Ploase attach a volded check to this authorization,