Form 301-Ef - Application For Withholding Tax E-File Participation - North Dakota Office Of State Tax Commissioner
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1Form
301-EF
APPLICATION FOR WITHHOLDING TAX E-FILE PARTICIPATION
NORTH DAKOTA OFFICE OF STATE TAX COMMISSIONER
SFN 28206 (3-99)
Taxpayer Information
Taxpayer’s Business Name
Please check appropriate box
Name of Contact Person
New E-File account
Mailing Address
Change contact name/address
City, State & Zip
Telephone Number
(
)
Change service group information
E-Mail Address
State Withholding Account Number (11 digits)*
Change bank account
* Your 9-digit federal ID plus the State’s 2-digit suffix
[
]
Complete this section only if a service provider will be making your payments
.
Service Provider Information
or if you are a service provider preparing this form for a taxpayer
Name of Service Provider
Name of Contact Person
Mailing Address
Telephone Number of Contact Person
City, State & Zip
E-Mail Address
An authorized officer or individual of the Service Provider must sign this form if payments are made from the Service
Provider’s bank account in order to authorize the North Dakota Office of State Tax Commissioner to debit that bank
account.
Service Provider’s Signature: ____________________________________________________
Date: __________________________
(Authorized Officer or Individual)
Print Name: ___________________________________________________________________
Title: __________________________
ACH Debit - Taxpayer initiates through the Office of State Tax Commissioner’s TeleFile system
I authorize the North Dakota Office of State Tax Commissioner (State), or its authorized agent, to initiate debit entries to the
following account. This authority remains in effect until 30 days after I give the State written notification to stop initiating ACH
debit entries to my account.
ACH Debit Bank Information
(Must complete. Attach a copy of a voided check to verify account)
Bank Name
Account Owner:
Taxpayer
Service Provider
Bank Telephone Number
Routing Transit Number (must be 9 digits) **
Type of Account:
Savings
Checking
Bank Account Number (not to exceed 17 digits) **
** See example of check for the location of these numbers.
By signing below, I understand I have applied for permission to file withholding tax returns and remit payment electronically via
the State’s Telefile system, and agree to follow the guidelines set forth in the Withholding Tax E-File handbook. I also
understand by completing the Service Provider Information section, I have designated the Service Provider to act as my
authorized representative in matters related to the filing of my withholding tax returns with the State, including the disclosure of
confidential withholding tax information on file with the State. Once I have been approved to file electronically via the Telefile
system, I will not receive a paper return from the State, and will be required to telefile each tax period. The authorization to
participate is in effect until it is terminated by either party.
Note: If this application is being completed by a Service Provider on behalf of the taxpayer, the taxpayer’s authorized signature must
be obtained to participate in E-File.
Taxpayer’s Signature: __________________________________________________________
Date: __________________________
(Authorized Officer or Individual)
Print Name: ___________________________________________________________________
Title: __________________________
Mail To: Office of State Tax Commissioner, Withholding Tax Section, 600 E. Boulevard Ave., Bismarck, ND 58505-0599
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