Form Eft-1 - Authorization Agreement For Touchtone Telephone Payments - 2009

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EFT-1
State of Arkansas
DEPARTMENT OF FINANCE AND ADMINISTRATION
Authorization Agreement for Touchtone Telephone Payments
EIGHT DIGIT ACCOUNT ID:
Withholding Wage Tax
EIGHT DIGIT ACCOUNT ID:
12304750
Withholding Wage Tax
Check one of the following boxes:
INITIAL FILING OF THE FORM
CHANGE OF BANKING INFORMATION
CHANGE IN CONTACT PERSON
EFFECTIVE DATE OF CHANGE
Name of Business or Organization
C
Phone (
)
Primary EFT Contact Person
O
N
Address
FAX
(
)
A
T
City, ST, ZIP
A
Email Address
C
Signature of officer or owner
T
Changes in Bank information must be submitted on this form with the new information at least 10 days prior to your
next payment date.
Choosing the Touchtone Telephone option authorizes the Department of Finance and Administration or its agent to
B
present debit entries to your bank for payments of your Withholding Wage Tax liabilities. Before any debit entries are
A
made to your bank account, you must first initiate the debit by calling the state's service bureau at its toll free number
and follow the instructions from the instruction card. An information packet with the instruction sheet and toll free
N
telephone number will be mailed to the primary contact person upon completion of this form. If you do not receive the
K
instruction sheet before the due date of your required EFT payment contact a customer service representative at the
phone number below.
B
I
Bank Name
N
F
PLEASE PRINT IN BLUE OR BLACK INK.
O
ROUTING NUMBER (MUST BE 9 DIGITS) ___ ___ ___ ___ ___ ___ ___ ___ ___
BANK ACCOUNT NUMBER ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
___
Checking
Savings
Withholding Wage Tax Type Code(s)
01100
Complete this form and return to:
EFT UNIT, P.O. BOX 3566, LITTLE ROCK, AR 72203-3566
Telephone: (501) 682-7105 - FAX: (501) 682-7904
R 01/2009

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