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Oklahoma Tax Commission

Electronic Funds Transfer

APPENDIX C

OKLAHOMA TAX COMMISSION

AUTHORIZATION AGREEMENT

FOR ELECTRONIC FUNDS TRANSFER (EFT) - ACH DEBIT

Method of Filing:

(Please check one)

Internet*___________

IVR*______________

Mail-In_______

*not available for all tax types

Complete section concerning the contact person this agency may call.

Indicate which tax(es) will

be payed by EFT and note the Tax Account Number for each tax to be paid.

COMPANY INFORMATION

Company/Organization:

Tax Acct/Permit Number

Tax Type Code

Address:

Contact Person’s Name:

Telephone No. (including Area Code):

E-mail Address:

FEI Number:

Signature and Title of Authorized Official: ____________________________________________ Date:_________________

****************************************************************************************************

FINANCIAL INSTITUTION INFORMATION

I authorize the State of Oklahoma Treasury and the financial institution named below to

initiate entries to my checking accounts.

This authority will remain in effect until I

notify you in writing to cancel it in such time as to afford the financial institution a

reasonable opportunity to act on it.

I can stop payment of any entry by notifying my

financial institution 3 days before my account is charged.

I can have the amount of an

erroneous charge immediately credited to my account up to 15 days following issuance of my

financial institution statement or 60 days after posting, whichever occurs first.

PLEASE ATTACH A COPY OF VOIDED CHECK

Name of Financial Institution:

Address of Financial Institution:

Checking Account No.:

Financial Institution Routing No. (Between these symbols |: |: on the bottom left of your check):

**********************************************************************************

I hereby authorize the Oklahoma Tax Commission to use the above information in direct conjunction with the

Electronic Funds Transfer Program.

This authority is to remain in full force and effect until the Oklahoma Tax

Commission has received a written termination notification from an authorized officer.

I will comply with the

Electronic Funds Transfer provisions set forth by the Oklahoma Tax Commission.

Signature of Authorizing Official: _______________________________________________

INSTRUCTIONS FOR COMPLETING THE ACH CREDIT AUTHORIZATION FORM

When completing the authorization agreement form, please note the following:

*Indicate whether forms will be submitted using either the Internet or IVR system or if they will be mailed in.

EFT

Revision Date: February 9, 2006

Page 19

Appendix C - Authorization Agreement For Electronic Funds Transfer (Eft) - Ach Debit - Oklahoma Tax Commission

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