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Eft Enrollment Form For Add New Enrollment Or Banking Change - Idaho State Treasurer

State of Idaho

Office of the State Treasurer

EFT Enrollment Form – Please print or type.

ADD NEW ENROLLMENT

BANKING CHANGE

EFT Tax Payment Type available. Please check all that apply:

Health and Welfare (agency code 270)

Department of Lands (agency code 320)

DEQ (agency code 245)

Public Health Dist. #4 (agency code 954)

Indicate which method you will use in sending your payment.

Automated Clearing House (ACH) Debit

Automated Clearing House (ACH) Credit

Federal Employer ID No. (9): __ __ __ __ __ __ __ __ __

Company Name (25): __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Contact (25): __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Address (25): __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

City (15): __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

State (2): __ __

Zip: __ __ __ __ __ - __ __ __ __

Primary Phone: (__ __ __) __ __ __ - __ __ __ __

Financial Institution Information (Debit method only)

If you are using the ACH Debit System, please include a voided check or a letter from your financial institution in order to

verify the American Bank Association Number and the Bank Account Number.

Transit (Routing) / ABA Number (9): __ __ __ __ __ __ __ __ __

Account Number (up to 17 digits): __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Checking

Savings

Other

_______________________

(Explain)

Authorization FOR DEBIT METHOD ONLY:

I (we) hereby authorize the financial institution indicated above to debit the above account, and transfer the debited

amount to the Idaho State Treasurer's account.

Name

Title

Signature

Date

Please retain a copy of this form for your records. Return the completed form to Ardie Noyes, Banking

Assistant, PO Box 83720, Boise, ID 83720-0091.

Eft Enrollment Form For Add New Enrollment Or Banking Change - Idaho State Treasurer