Form Eft-1 - Authorization Agreement For Electronic Funds Transfers

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STATE OF CONNECTICUT
Connecticut Tax Registration Number
EFT-1
DEPARTMENT OF REVENUE SERVICES
25 Sigourney Street
Tax Type
Authorization Agreement
Hartford CT 06104-2937
for
(Rev. 02/01)
Electronic Funds Transfers
See back for instructions
Enter company name and mailing address
PLEASE PRINT OR TYPE
This section must be completed by ALL Taxpayers
C
O
Primary EFT Contact Person: __________________________________________________________________________________________
N
T
Address: _________________________________________________________________________________________________________
A
(
)
C
_________________________________________________________________________________________________________________
T
City
State
ZIP
Telephone Number
A
P
E
Secondary EFT Contact Person: _______________________________________________________________________________________
R
S
Address: _________________________________________________________________________________________________________
O
(
)
N
_________________________________________________________________________________________________________________
City
State
ZIP
Telephone Number
S
Payment Options - Choose one payment option
ACH Debit Option - Complete this section only if you choose the ACH Debit Option
You are authorizing the Connecticut Department of Revenue Services to present debit entries to your bank for the tax identified above. Only
you can initiate a debit by calling the State’s Service Bureau and indicating the amount of tax to be paid by electronic funds transfer.
Confirm your bank account number and routing/transit number with your bank representative.
Bank Name: ________________________________________________________________________________________________________
A
C
H
B
Bank Address: ______________________________________________________________________________________________________
D
E
__________________________________________________________________________________________________________________
B
Street
City
State
ZIP Code
I
T
Bank Account Number: _________________________________ Bank Routing/Transit Number: ____________________________________
~
~
Checking
Savings
(
)
__________________________________________________________________________________________________________________
Print Name of Bank Representative
Telephone Number
__________________________________________________________________________________________________________________
Signature of Owner, Partner or Taxpayer’s Officer
Date
ACH Credit Option - Complete this section only if you choose the ACH Credit Option
Confirm with your bank representative that you and your bank are capable of initiating ACH credits in the required CCD+TXP format.
A
C
Bank Name: ________________________________________________________________________________________________________
H
C
C
Bank Address: ______________________________________________________________________________________________________
R
Street
City
State
ZIP Code
E
D
(
)
__________________________________________________________________________________________________________________
I
Print Name of Bank Representative
Telephone Number
T
__________________________________________________________________________________________________________________
Signature of Owner, Partner or Taxpayer’s Officer
Title
Date

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