Form Eft-Wh Draft - Authorization Agreement For Electronic Funds Transfer Of Arkansas Withholding Tax

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EFT-WH
STATE OF ARKANSAS
Authorization Agreement for Electronic Funds
Transfer of Arkansas Withholding Tax
Arkansas Withholding Tax/Federal Identification Number: ________________________________
Check one of the following boxes:
Initial Filing of the EFT Agreement Form
Change of Bank or Other Information
Are you a Tax Service Provider?
YES
NO (If yes, use ACH CREDIT only)
Name of Business or Organization: __________________________________________________________
C
Primary EFT Contact Person: __________________________________ Phone: (
) _______________
O
Address: __________________________________________________ Fax:
(
) _______________
N
City, State, Zip: _____________________________________________
A
T
Secondary EFT Contact Person: ________________________________ Phone: (
) _______________
A
Address: __________________________________________________ Fax:
(
) _______________
C
T
City, State, Zip: __________________________________________________________
)
(S
Business Email Address: ___________________________________________________
Signature of Owner, Partner, or Officer
Date
CHOOSE ONLY ONE OF THE TWO PAYMENT OPTIONS BELOW
Complete this section only if you choose the ACH DEBIT OPTION (See Instructions). An AUTHORIZED
REPRESENTATIVE of your bank must complete and sign this section of the form.
Bank Name: ____________________________________________________________________________
A
C
Bank Address: __________________________________________________________________________
H
City, State, Zip: _________________________________________________________________________
Bank Account # : ______________________________ Routing/Transfer # : _________________________
B
D
Checking
Savings
E
Name of Bank Representative: _____________________________________________________________
B
I
Signature of Bank Representative
Date
T
Signature of Owner, Partner, or Officer
Date
Complete this section only if you choose the ACH CREDIT OPTION (See Instructions). An AUTHORIZED
A
REPRESENTATIVE of your bank must complete and sign this section of the form.
C
Bank Name: ____________________________________________________________________________
H
Bank Address: __________________________________________________________________________
City, State, Zip: _________________________________________________________________________
C
C
R
Name of Bank Representative: _____________________________________________________________
E
D
Signature of Bank Representative
Date
I
T
Signature of Owner, Partner, or Officer
Date
COMPLETE THIS FORM AND RETURN TO:
EFT Withholding Branch
P. O. Box 8055
Little Rock, AR 72203-8055
Telephone: (501) 682-7299 - FAX (501) 683-1036
EFT-WH (R 10/29/09)

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