Eft-1 - Authorization Agreement For Electronic Funds Transfers Form

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Department of Revenue Services
EFT-1
Connecticut Tax Registration Number
25 Sigourney Street
Hartford CT 06104-2937
Authorization Agreement for
Tax Type
Electronic Funds Transfers
(Rev. 12/05)
See back for instructions.
Enter company name and mailing address.
Part 1: Electronic Funds Transfer (EFT) Contact
All taxpayers must complete this section. Please print or type. Complete in blue or black ink only.
Primary EFT Contact Person: ______________________________________________________________________________________________________
(
)
______________________________________________________________________________________________________
Telephone Number
Email Address
Address: ______________________________________________________________________________________________________________________
Street
City
State
ZIP Code
Part 2: Payment Options
ACH Debit (Direct Payment)
To make a direct payment using the Department of Revenue Services (DRS) Fast-File system, you do not have to submit the
EFT-1 to DRS. Simply access Fast-File on the DRS web site at or by telephone at 860-947-1988.
ACH Credit
Payment related information must be sent in the standard National Automated Clearing House Association (NACHA) CCD + TXP
format. Confirm with your bank representative that you and your bank are able to initiate ACH credit transactions. We will mail
instructions and formats to the EFT contact person after we receive a completed authorization agreement.
Please provide the following information.
Bank Name: ____________________________________________________________________________________________________________________
Bank Address: _________________________________________________________________________________________________________________
Street
City
State
ZIP Code
Taxpayer Signature: _____________________________________________________________________________________________________________
(Owner, Partner, or Corporate Officer)
Title
Date

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