Form Eft-Ct - Authorization Agreement For Electronic Funds Transfer Of Arkansas Corporation Estimated Income Tax

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EFT-CT
State of Arkansas
CLICK HERE TO CLEAR FORM
DEPARTMENT OF FINANCE AND ADMINISTRATION
Authorization Agreement for Electronic Funds Transfer of Arkansas
Corporation Estimated Income Tax
Federal EmpIoyer Identification Number (FEIN):
Check one of the following boxes:
Initial Filing of the EFT Agreement Form
Change of Bank or Other Information
PLEASE PRINT OR TYPE
Name of Business or Organization
C
Primary EFT Contact Person
Phone (
)
O
Address
FAX (
)
N
City, ST, ZIP
Secondary EFT Contact Person
Phone (
)
A
T
Address
FAX (
)
A
City, ST, ZIP
C
T
Signature of Corporate Officer
Title
Date
(S)
CHOOSE ONLY ONE OF THE TWO PAYMENT OPTIONS BELOW
Complete this section only if you choose the ACH DEBIT OPTION
If ACH Debit is chosen, you authorize the Department of Finance and Administration or it's agent to present debit entries to your bank for the tax specified
above. Only you can initiate a debit by calling the State's Service Bureau and indicating the amount of the tax to be paid by EFT.
A
C
An AUTHORIZED REPRESENTATIVE
of your bank must complete and sign this section of the form.
H
Bank Name
Bank Address
City, ST, ZIP
B
Bank Acct. #
Routing/Transfer #
D
Checking
Savings
E
Printed Name of Bank Representative
B
I
Signature of Bank Representative
Title
Date
T
Signature of Corporate Officer
Title
Date
A
Complete this section only if you choose the ACH CREDIT OPTION
C
An AUTHORIZED REPRESENTATIVE
of your bank must sign this section of the form confirming that you and your bank are
H
.
capable of initiating ACH Credits in the required CCD + TXP format
Bank Name
C
C
Bank Address
R
City, ST, ZIP
E
Printed Name of Bank Representative
D
I
Signature of Bank Representative
Title
Date
T
Signature of Corporate Officer
Title
Date
Complete this form and return to: Corporation Income Tax Section, P.O. Box 919, Little Rock, AR 72203-0919 Telephone: (501) 682-4785 FAX: (501) 682-7114
(SEE BACK FOR INSTRUCTIONS)

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