Tax Division Enrollment Form - Alaska printable pdf download

STATE OF ALASKA

TAX DIVISION

ENROLLMENT FORM

NEW ENROLLMENT

MODIFY

DELETE

ADD (Financial Information/Contact)

Questions regarding this Enrollment Form should be directed to Alaska State Automated Payment Customer Service at 800-204-6394. Use blue or black ink only.

1. Federal Employer ID No or SSN: ___ ___ ___ ___ ___ ___ ___ ___ ___

2. Customer Name: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

3. Customer Address (35): ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

4. City (35): ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

State: ___ ___

Zip: ___ ___ ___ ___ ___-___ ___ ___ ___

5. Province: ___ ___

Country: ___________

Postal Code (6): ___ ___ ___ ___ ___ ___

CONTACT INFORMATION

6. Primary Contact (35): ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

7. Primary Contact Phone Number: (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___

E-Mail: _________________________________

8. Primary Contact Address (if different from #3 above): ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

9. City (35): ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ State: ___ ___

Zip: ___ ___ ___ ___ ___-___ ___ ___ ___

10. Province: ___ ___

Country: ___________

Postal Code (6): ___ ___ ___ ___ ___ ___

FINANCIAL INSTITUTION INFORMATION:

You must designate a depository financial institution that can receive and process ACH entries. Please note that Canada does not participate in the ACH

system. Please consult your financial institution’ s representative to verify their processing services as well as your account information. A zero-dollar prenote

item will be sent to your financial institution upon enrollment. During this time (at least six business days), your account will be placed in prenote status thus

prohibiting the initiation of any payments to your account.

13. Transit (Routing)/ABA Number (9): ___ ___ ___ ___ ___ ___ ___ ___ ___

14. Account Number (up to 17 digits): ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

15. Checking o

Savings

16. Modify Effective Date:

___ ___ ___ ___ ___ ___

17. Payment Type (5): _____________________________________

(Specify only when enrolling multiple bank accounts).

THRESHOLD (Optional):

Under ACH rules, no single payment can exceed $99,999,999.99. For more restricted control, you may establish a smaller threshold amount to ensure that

your payment does not exceed this amount.

18. Payment Threshold (Maximum):

$ ___ ___ , ___ ___ ___ , ___ ___ ___ . 00

AUTHORIZATION:

I hereby authorize the State of Alaska to initiate ACH Debit entries to the financial institution account indicated above upon request by the taxpayer

or his/her representative. I also authorize the financial institution indicated above to debit the account indicated above. This authorization shall

remain in full force and effect until written notification is made to the State of Alaska of termination.

___________________________________

_______________________ __________________________ __________

Print Name

Title

Signature

Date

. R

LEASE RETAIN A COPY OF THIS FORM FOR YOUR RECORDS

ETURN THE COMPLETED FORM TO

LASKA