Direct Payment Authorization Request Form

The Direct Payment program allows you to make payments on your Wise County taxes automatically each month. When you enroll in the Direct Payment program, we will deduct the amount you choose to be applied to your local taxes monthly. The deduction will be on or about the 5th day of each month. To sign up for the Direct Payment plan, you will need to complete and sign an electronic authorization form located below, or contact the Wise County Treasurer's Office to obtain an authorization form. Please contact the Wise County Treasurer's Office with questions or for more information.

Consumer Authorization for Direct Payment Via ACH (ACH Debits)

Taxpayer Information
First Name
Last Name
Tax Account Number(s)
Address
City
State
Zip Code
Phone Number
Email Address
Banking Information
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:
Select One:
1. Checking Account
2. Savings Account
at the depository financial institution named below.
I (we) agree that ACH transactions I (we) authorize comply with all applicable law.
Depository Bank Name/Branch Office
Address
City
State
Zip
Depository's Transit Routing Number (9 digits)
Depository Account Number
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.
Requested Month to Begin
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).
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.
Electronic Signature
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.
Electronic Signature

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

This field is not part of the form submission.
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