Form Eft-100 - Electronic Funds Transfer Authorization Agreement

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Electronic Funds Transfer
EFT-100
Authorization Agreement
10-06
North Carolina Department of Revenue
Office Use
Federal Employer ID Number
Only
Name
(First 30 Characters) (USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS)
Social Security Number
Address
Fill in applicable circle:
City
State
Zip Code (First 5 digits)
Initial registration - mandatory participant
Initial registration - voluntary participant
Change of Information/Bank Change
(Effective Date: ____________ )
Account ID Number
Name of Contact Person
Phone Number
0 0
Motor Fuels Account ID Number
Title
Fax Number
Fill in applicable circle for tax type:
Address
Alcoholic Beverage
Sales & Use
(Semimonthly only)
Corporate Income
Tobacco Products
Insurance Premium
City
State
Zip Code (First 5 digits)
Utilities Franchise
Machinery, Equipment,
Utility & Liquor
& Manufacturing Fuel
Sales & Use Tax
Motor Fuels
Withholding
Piped Natural Gas
General Instructions
Complete Part 1 to choose the ACH Debit method. Complete Part 2 to choose the ACH Credit method.
Part 1.
ACH Debit
1.
Payment Method
Touchtone
Voice
PC Software
Fill in applicable circle:
2.
Financial Institution Name
3.
Account Type
Checking
Savings
Fill in applicable circle:
4. Transit or Routing Number
5. Bank Account Number
Part 2.
ACH Credit
Part 3.
Authorized Signatures
(ACH Debit filers must complete both certifications. ACH Credit filers must complete the bottom certification.)
I authorize the Department of Revenue to present debit entries for the bank account and the financial institution named above. Debit transactions will be presented only
upon my express authorization and initiation and will pertain only to electronic funds transfer payments that are initiated for payment of North Carolina taxes.
Authorized Signature
Title
Date
I certify that the individual named above as the contact person is authorized to act on behalf of the taxpayer.
Authorized Signature
Title
Date
MAIL TO: Electronic Funds Transfer Section,
North Carolina Department of Revenue, P.O. Box 25000, Raleigh, North Carolina 27640-0001

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Parent category: Financial
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