Print
Clear
EFT-003 (Rev. 3/11)
STATE USE ONLY
GEORGIA EFT
I
C
F
NFORMATION
HANGE
ORM
Change should be submitted 30 days prior to effective date.
EFFECTIVE DATE:__________________
LOCATOR NUMBER
CURRENT INFORMATION ON FILE:
CHANGE TO:
Taxpayer Name: _________________________________
Taxpayer Name: _________________________________
Email Address: _________________________________
Email Address: _________________________________
Address:________________________________________
Address:________________________________________
City/State/Zip:___________________________________
City/State/Zip:___________________________________
Sales/With/Corp Tax ID#: _________________________
Sales/With/Corp Tax ID#: _________________________
Type of Tax Payment:_____________________________
Type of Tax Payment: _____________________________
st
st
1
Contact Person:________________________________
1
Contact Person:________________________________
Phone: _________________ Fax:____________________
Phone:_________________ Fax:____________________
nd
nd
2
Contact Person: _______________________________
2
Contact Person:_______________________________
Phone: _________________ Fax:____________________
Phone:_________________ Fax:____________________
Bank: __________________________________________
*Bank: _________________________________________
Mailing Address: _________________________________
*Mailing Address:________________________________
City/State/Zip: ___________________________________
*City/State/Zip:__________________________________
Transit/Routing #: ________________________________
*Transit/Routing #: _______________________________
Bank Account #: _________________________________
*Bank Account #: ________________________________
[ ] Checking
[ ] Savings (check one)
[ ] Checking
[ ] Savings (check one)
Day Phone: __________________Fax: _______________
Day Phone: __________________Fax: _______________
Bank Contact Person: _____________________________
Bank Contact Person: _____________________________
Checking account: please attach a voided check
Checking account: please attach a voided check
Saving account: please attach a voided deposit slip
Saving account: please attach a voided deposit slip
*ITEMS MARKED WITH AN ASTERISK MUST BE COMPLETED IN ORDER TO PROCESS CHANGE (S)
I/we authorize the Georgia Department of Revenue-EFT Section to make changes to current information on file in regards to my EFT payment.
Begin making EFT transaction using new information on the effective date above.
Signature: ________________________________________________Title: ___________________________Date:_______________
Please complete and return by mail or fax: 404-417-4398
Georgia Department of Revenue-EFT Section
1800 Century Center Blvd N.E., Suite 7200
Atlanta, GA 30345
CONFIRMATION BY NDC INDICATING CHANGE HAS BEEN COMPLETED THIS_________DAY OF__________________, 20____
Signature and Title