Electronic Funds Transfer Authorization Agreement Form printable pdf download

ELECTRONIC FUNDS TRANSFER AUTHORIZATION AGREEMENT

ATTN:

ELECTRONIC FUNDS COORDINATOR

THE STATE OF DELAWARE, DIVISION OF REVENUE

P.O. BOX 8754

WILMINGTON, DE

19899-8754

PHONE: (302) 577-8231

FAX: (302) 577-8203

BUSINESS NAME:

______________________________________________________________________

MAILING ADDRESS:

______________________________________________________________________

CITY, STATE & ZIP:

______________________________________________________________________

FEDERAL ID #:

______________________________________________________________________

CONTACT PERSON:

PHONE NUMBER:

PLEASE CHECK APPLICABLE BOX

ESTABLISH NEW EFT

MODIFY

CHANGE BANK

ACCOUNT

EXISTING SET-UP

ACCOUNT

SELECT THE TYPE OF TAX TO BE PAID, PLEASE USE THE LIST BELOW.

______ 01106 FOR DELAWARE WITHHOLDING TAX PAYMENTS

______ 02101 FOR CORPORATE TENTATIVE TAX PAYMENTS

______ 14982 FOR “S” CORPORATION ESTIMATED TAX PAYMENTS

SELECT PAYMENT OPTION

ACH DEBIT OPTION – TAXPAYER PHONES IN TAX PAYMENT

I hereby authorize the State of Delaware, Division of Revenue, upon my initiation only, to accept Automated Clearing House transactions as payment on

any account.

I also authorize the State of Delaware, Division of Revenue, to release any of the taxpayer and

institution information, as deemed

necessary to enable payment by electronic funds transfer, to the data collection service selected by the Division.

This authorization is to remain in full

force and

until the State of Delaware , Division of Revenue has received written

of change.

Enter bank account information in the space provided below; this account information should pertain to the account from which you wish the tax

payments to be drawn using the ACH debit method of payment.

ATTACH ONE of the following: A voided check, a completed micro spec sheet, or

letter from your bank verifying the bank account information listed below.

Bank Routing & Transit #

Bank Account Number

Type of Bank Account

ACH CREDIT OPTION – TAXPAYER INITIATES PAYMENT THROUGH THEIR OWN BANK

I hereby authorize the State of Delaware, Division of Revenue, to grant authority for the above named taxpayer to initiate Automated Clearing House

transactions to the Division of Revenue’s bank account. I understand these transactions must be in the NACHA CCD+ format, using the Tax

Payment Convention and may only be initiated for the Tax Types that have been registered for Electronic Funds Transfer payments by the State of

Delaware, Division of Revenue. I will initiate an ACH Pre-Note through my

institution within six (6) days prior to start-up of service.

Authorized Signature:

______________________________________________________Date :________________________

PLEASE MAIL THE COMPLETED AUTHORIZATION FORM TO THE ADDRESS LISTED ABOVE.

Electronic Funds Transfer Authorization Agreement Form

Related Articles

Related forms

Related Categories