AUTHORIZATION AGREEMENT FOR ACH DIRECT WITHDRAWALS
For Property Tax and/or Sewer Utility Payments 

Check One:    New Authorization                      Authorization to Change Bank or Account Number

Authorization for:  Property Tax       Sewer Payment       Both Tax and Sewer

I (we) authorize the Township of Chesterfield to initiate debit entries to my (our) checking account or savings account indicated below and I hereby authorize the bank named below to debit the same to such account.

Bank Name:     Branch: 

City:      State:       Zip Code: 

ABA Routing Number:      Account Number: 

This authority is to remain in full force and effect until Chesterfield township has received WRITTEN notification from me of its termination in such time and in such a manner as to afford Chesterfield Township and the Bank a reasonable opportunity to act on it and in no event shall a termination notice be effective with respect to entries processed by the Township or the Bank prior to its receipt.  All insufficient funds will incur a $20.00 fee.  I (WE) UNDERSTAND THAT MY (OUR) BANK ACCOUNT WILL BE DEBITED ON THE 3rd OF THE MONTH THE TAX PAYMENT IS DUE.

The personal information provided in this form by the taxpayer shall remain confidential from all other sources and used solely for the purposes described in this form.

Name(s): 

Property Location: 

Mailing Address: 

Block:     Lot:    Qualifier:    Sewer Acct No: 

Signature:  _________________________  Signature:  _____________________________

Date:  _____________________ Daytime Phone or Cell Phone #: 

Attach VOIDED CHECK HERE OR FOR SAVINGS ACCOUNT, A DEPOSIT SLIP
Send completed and signed form with either voided check or savings account deposit slip to:

Chesterfield Township
Office of the Tax Collector
300 Bordentown-Chesterfield Road
Chesterfield, NJ  08515