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2. Taxpayer Information
4. First Name
5. Last Name
7. Tax Account Number(s)
9. Address
11. City
12. State
13. Zip Code
15. Phone Number
17. Email Address
19. Banking Information

21. I (we) authorize Wise County Treasurer to electronically debit my (our) accounts (and, if necessary, electronically credit my (our) account to correct erroneous debits) as follows:

23. Select One:

    1. Checking Account
    2. Savings Account

    at the depository financial institution named below.

25. I (we) agree that ACH transactions I (we) authorize comply with all applicable law.
27. Depository Bank Name/Branch Office
28. Address
30. City
31. State
32. Zip
34. Depository's Transit Routing Number (9 digits)
36. Depository Account Number
38. Monthly Deduction Amount

    This set amount will be taken out of your account once per month, on or around the 5th day of the month.

39. Requested Month to Begin

41. I (we) understand that this authorization will remain in full force and effect until I (we) notify Wise County Treasurer, in writing, that I (we) wish to revoke this authorization. I (we) understand that Wise County Treasurer requires at least 7 days prior notice in order to cancel this authorization. I (we) further understand that Wise County Treasurer will initiate, as applicable, requested subsequent entries in accordance with the terms of this standing Authorization, unless revocation is initiated as per the above method(s).

43. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
45. Electronic Signature
47. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
49. Electronic Signature
Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field