Authorization Instructions & Agreement For Electronic Funds Transfer (Eft) For Excise Tax Payments Form - Washington Department Of Revenue
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1Please Check One
AUTHORIZATION INSTRUCTIONS & AGREEMENT
State of Washington
(DOR Use Only)
Department of Revenue
PO Box 47476
FOR ELECTRONIC FUNDS TRANSFER (EFT)
New
Olympia WA 98504-7476
Change
FOR EXCISE TAX PAYMENTS
Bank Location
Important:
The information provided on this form does not give the Washington State Department
No.______________
of Revenue (DOR) or the Department’s bank authorization to withhold from your
ELF
account funds not authorized for payment to the Department.
(Touch Tone)
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DOR Tax Reporting Account
I
Instructions on Back
Number
Business Ownership (Legal Entity)
Check here if name change
Firm/Trade Name (DBA)
Mailing Address (Street Address, Box Number, City, State, Zip)
E-mail Address
Fax Number
(
)
Contact Name
Title
Phone
(
)
Contact Name
Title
Phone
(
)
II Automated Clearing House (ACH) Debit
I will be responsible for contacting the ACH Network, specifying the amount and effective date of my payment. I will do
this by either using the DOR Electronic Filing (ELF) system or by using the backup EFT instructions provided by the
Department’s designated bank. I hereby authorize DOR’s designated bank to obtain authorized debit entries for such
payments to the bank account listed below. My bank is authorized to debit such account. This authority is to remain in full
force until EFT payments are no longer required or until mutual agreement between DOR and Taxpayer can be reached.
Name on Bank Account
Checking Account Number
Bank Name
Transit & Routing Number
Branch
Please Attach a Copy of Voided Check
Ø Ø
III
Electronic Refund Information
Electronic refunds may be provided for taxpayers paying electronically. Please indicate below the bank information
necessary to credit the account for refunds. A refund check will be processed if this section is not completed.
Name on Bank Account
Checking Account Number
Bank Name
Transit & Routing Number
Branch
Please Attach a Copy of Voided Check
Ø Ø
IV Authorized Representative Signature(s)
Name
Title
Signature
Date
07/18/00
/
/
Name
Title
Signature
Date
07/18/00
/
/
Mail to: Department of Revenue
Electronic Filing Registration & Support
PO Box 47476
Olympia WA 98504-7476
REV 41 0060ELF-1 (10-6-99)
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