I hereby authorize the Pike County Collector, hereinafter called COLLECTOR, to initiate the debit entries to my checking account / savings account at the depository financial institution (named below), hereinafter called DEPOSITORY, and to debit the same to such account. I acknowledge that the origination of APS transactions to my account must comply with the provisions of U.S. law. I understand that failure to notify COLLECTOR of any account changes that result in a payment not being honored by the financial institution may result in late penalty and interest charges for which I, as the taxpayer, will be responsible. By signing this authorization form, I agree to participate in the AUTOMATED PAYMENT SERVICE program as outlined in this payment agreement until further notice.
(Voided check is required - attach to this form)