Form Ftb 3815 - Authorization Agreement For Electronic Funds Transfer (Eft) - California
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STATE OF CALIFORNIA
FRANCHISE TAX BOARD
Authorization Agreement for Electronic Funds Transfer (EFT) (See Reverse for Instructions)
Check appropriate box:
New EFT Account
Change Bank Account
Change EFT Payment Method
Change Contact Information
SECTION I
Entity Name
Entity Identification
Entity Address (number, street, box number)
Daytime Telephone
(
)
Entity Address (city, state and ZIP code)
FAX Number
Contact Person
E‑Mail Address
Contact Daytime Telephone
(
)
Contact Address (number, street, box number)
Contact Address (city, state, and ZIP code)
Complete Section II or III below.
SECTION II
ACH Debit
The Franchise Tax Board is hereby authorized to process debit entries to the bank account identified below upon initiation by the
above‑named entity. This authority is to remain in full force until EFT payments are no longer required by statute or until the Franchise
Tax Board and I mutually agree to terminate my participation in the EFT program.
In addition, the individuals named below are authorized to establish a new security code if my selected code is lost or forgotten.
Signature
Print
Title
Date
Signature
Print
Title
Date
Bank Name and Address
Bank Account Number
Bank Transit and Routing Number
Checking
Savings
Method(s) to be used in communicating payment information:
Telephone
Personal Computer
IMPORTANT: If you have selected the ACH debit option, please attach a voided check from the account to be debited. Your
voided check will provide bank transit and routing numbers.
SECTION III
ACH Credit
The Franchise Tax Board is hereby requested to grant authority for the above‑named entity to initiate ACH credit transactions to the
Franchise Tax Board’s bank account. These payments must be in the NACHA CCD+ format using the Tax Payment Convention (TXP)
and may only be initiated for the EFT tax payments to the Franchise Tax Board provided for by statute.
Signature
Print
Title
Date
Signature
Print
Title
Date
Bank Name and Address
Bank Contact Person
Bank Contact Telephone
(
)
Return to: Franchise Tax Board / Attn: EFT Unit / PO Box 1468 / Sacramento, CA 94257-0501 / or Fax to: 916.855.5556
Please make a copy for your records
381500091371
FTB 3815 (REV 04-2014) SIDE 1
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