Bank Information Change Form - Ach Debit
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1EFT-BIC
Indiana Department of Revenue
Date: __________________
State Form 50109
EFT
(R3 /6-10)
Bank Information Change - ACH Debit
This is for bank change only, it does NOT replace the Authorization Agreement Form (EFT-1)
13 digit Indiana TID # : _______________________________________________________________________
Company Name: ___________________________________________________________________________
Tax Types: ________________________________________________________________________________
New Bank Information
Bank ABA# : ______________________________________________________________________________
(Transit Routing #)
(Nine Digits)
o
o
Checking
Savings
Bank Account # : ___________________________________________________________________________
This change must be effective by: _______________________________________________________________
o
o
Will the funds for the ACH Debit payments come from a bank outside of the United States?
No
Yes
Please print for legibility. The following information is for EFT purposes only.
Company Contact Person: ____________________________________________________________________
Address: __________________________________________________________________________________
__________________________________________________________________________________
Telephone Number: _____________________________________________________
Ext: ______________
_____________________________________________________________________
_________________
Authorized Signature
Date
Please attach a voided check to verify the new bank information. Note: Deposit slips do not always have the same ABA/Transit Routing
number as the checking/savings account.
EFT Section, Room N248
Indiana Department of Revenue
100 N. Senate Ave.
Indianapolis, IN 46204-2253
or FAX to: (317) 232-1851 Attn: EFT Section
We will confirm the requested change(s) in writing or by telephone. If you have any questions, contact the EFT Section at (317) 232-5500.
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