Form Lb-0963 - Electronic Funds Transfer Agreement
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STATE OF TENNESSEE
DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
DIVISION OF EMPLOYMENT SECURITY
EMPLOYER ACCOUNTS OPERATIONS
220 FRENCH LANDING DRIVE
NASHVILLE, TENNESSEE 37243
PHONE: 615-741-2346
FAX: 615-741-7214
ELECTRONIC FUNDS TRANSFER AGREEMENT
Employer Name: ____________________________________________________________________________
State UI Account Number: _________ - _________
Federal EIN: _____ - _____________________
Contact Person: ______________________________
Telephone Number: ______________________
E-mail Address: __________________________________
Fax Number: ___________________________
This is an agreement between the Tennessee Department of Labor and Workforce Development (hereinafter
“TDLWD”) and _______________________________________________________________________ (hereinafter
“the Employer”), entered into this on this the ___________ day of _____________________, ________ pursuant to
the provisions of T.C.A. § 50-7-404, Rule 0800-10-01-.01 et. seq.
TDLWD and the Employer agree as follows:
1. The TDLWD authorizes the employer to transmit electronically using the Automated Clearing House (ACH),
unemployment insurance premiums (hereinafter “Funds”), due quarterly to the Department by the employer.
2. The premium due dates will remain the same with regard to interest. TDLWD must receive the funds by the due date
or appropriate interest will be assessed.
3. It is the responsibility of the employer to transmit funds so as to be received by TDLWD’s bank by the due date.
4. This Agreement will be effective beginning ______________________ quarter/year.
Employer or Agent Signature
TDLWD Official Signature
_________________________________________________
________________________________________________
Employer or Agent Name Printed
Title
_________________________________________________
________________________________________________
Title
_________________________________________________
Date _________________
Employer or Agent Telephone Number
_______________________________________
Date _________________
LB-0963 (Rev. 10-12)
RDA 2438
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