AUTOMATIC ACCOUNT DEBIT AUTHORIZATION …

1 BERKS EIT BUREAU1125 Berkshire Blvd., Suite 115, Wyomissing, PA 19610 Telephone: 610-372-8439 Toll Free: 1-855-372-8439 Fax: 610-372-1102 Email: ACCOUNT DEBIT AUTHORIZATION AGREEMENTTHIS AUTOMATIC ACCOUNT DEBIT AUTHORIZATION agreement authorizes the Berks CountyEarned Income Tax Bureau (the Bureau ) to deduct amounts equal to the undersigned employer sEarned Income Tax and/or Local Services Tax payments that are otherwise due and owing from time totime (the Tax Payments ) from the bank ACCOUNT listed below (the ACCOUNT ) and to remit such TaxPayments directly to the Bureau (or other applicable taxing authorities). Any employer electing toutilize this service must be registered through the Bureau s on-line sign-in feature located The undersigned employer is instructed to print, complete and mail this form,along with a voided check or copy of the employer s bank ACCOUNT statement, to the Bureau at theaddress set forth completing this AUTOMATIC ACCOUNT DEBIT AUTHORIZATION agreement and signing below, theundersigned employer hereby authorizes and directs the Bureau, on its behalf, to DEBIT the ACCOUNT inthe amount of the Tax Payments and to remit such Tax Payments to the Bureau (or other applicabletaxing authorities).

2 This AUTHORIZATION shall remain in full force and effect until the Bureau receiveswritten notice from the undersigned employer of its termination, which notice shall be sent to the address noted above. Is this a banking change?_____ACCOUNT INFORMATIONBERKS EIT ACCOUNT # _____EMPLOYER NAME _____BANK ACCOUNT TYPE (SELECT ONE): _____CHECKING _____SAVINGSNAME OF BANK: _____BANK ACCOUNT NUMBER: _____BANK ROUTING NUMBER: _____ Authorized SignatureDatePrint Name: _____ Title: _____Contact Telephone #: _____ Email: _____