Form Dr 600f-Registration/authorization Form

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DR-600F
Registration/Authorization Form
R. 10/01
Florida e-Services Program
Electronic Tax Payment System
Business Name: __________________________________________________
Location Address: _________________________________________________
City / State / ZIP: __________________________________________________
1. Account Information:
Account Number (Sales tax certificate, license, etc.): ___________________________________
Type (Sales, Fuel, Unemployment, etc.): _____________________________________________
2. Payment Method
ACH- Debit
or
ACH-Credit
(Check either Debit or Credit)
(Must provide valid business reason — written request required.)
3. Contact Person at Business _____________________________________________________
Name
Phone Number
__________________________________________________________________________________________________________
Address
City / State / ZIP
Fax Number
4. Banking Information
(to be completed only for ACH-Debit)
(Bank changes require 30 days prior notice.)
Check here for bank change only.
Effective date of bank change: ____________________________________________
Bank Name: ________________________________________________________________________________________________
Bank Address: ______________________________________________________________________________________________
Street / City / State / ZIP
Bank Account No.: __________________________________ Bank Transit/Routing No.: ___________________________________
Verification of both your bank account number and the American Bank Association number (Transit/Routing No.) must be submitted
by a letter from your bank or by completion of the section below by a bank representative for ACH-Debit accounts.
___________________________________________
_________________________
_________________________
Signature of Bank Representative
Title
Date
5. Signatures
ACH-DEBIT: I/We hereby authorize the Florida Department of Revenue to present debit entries into the bank account referenced
above and the depository named above. These debits will pertain only to electronic funds transfer payments that the taxpayer has
initiated for payment of Florida taxes.
___________________________________________
_________________________
_________________________
Signature
Title
Date
___________________________________________
_________________________
_________________________
Signature
Title
Date
ACH-CREDIT: I am authorized to register for the ACH-Credit method payment privilege and accept all responsibility for the filing of
payments through ACH-Credit.
___________________________________________
_________________________
_________________________
Signature
Title
Date
This form must be completed and mailed to:
Phone:
Florida Department of Revenue
850-487-7972 or 1-800-352-3671 (in Florida Only)
e-Services Unit
Fax:
PO Box 5885
850-922-5088 (Bank Changes Only)
Tallahassee, FL 32314-5885

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