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Dallas County Treasurer 800 Court St Suite 111 Adel, IA 50003 Dallas County Treasurer Phone (515) 993-5808 I Fax (515) 993.5855 I Email: [EMAIL REDACTED] Authorization for ACH Payments I hereby authorize the Dallas County Treasurer, hereinafter called “Company,” to initiate debit and credit entries to my account indicated below and the Financial Institution named below, hereinafter called “Financial Institution,” for titles processed. I acknowledge that the origination of ACH transactions to my account must comply with U.S. law. Account Details Financial Institution Name: City: State: Zip: Routing Number: Account Number: Type of Account: Checking Savings Tax Sale Buyer Details Company name: Contact(s): Contact E-mail Address(s): Addresses: City: State: Zip: Telephone Number(s): This authorization is to remain in full force and effect until Company has received notification from me (or any authorize account signer) of its termination in such time and manner as to afford the Company a reasonable opportunity to act on the request. Print Individual Name: Signature: Date: *PLEASE ATTACH A VOIDED CHECK*