Fillable Agreement Per Ohio Tax Id Number Form printable pdf download

Agreement Per Ohio Tax Id Number Form

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JOSEPH T. DETERS

TREASURER OF STATE

Authorization Agreement

Electronic Funds Transfer

PLEASE COMPLETE ONE AGREEMENT PER OHIO TAX ID NUMBER

Part I TAXPAYER INFORMATION (REQUIRED)

Federal ID Number

Please type or print information

Taxpayer Name

Contact Person

Mailing Address (Street Number, Box Number)

Telephone Number

City

State

Zip Code

Fax Number

E-mail Address

Payroll Service

¨ NEW ACCOUNT

¨ MODIFY ACCOUNT

Part II TAX TYPE

¨ Sales and Use Tax

¨ Public Utilities Tax

OHIO TAX ID NUMBER

¨ Corporate Franchise Tax

¨ Withholding Tax

_________________________

¨ Motor Vehicle Fuel Tax

Select preferred payment option by completing either Part III ACH Debit OR Part IV ACH Credit.

When setting up or modifying an account, check the box next to the applicable tax type and enter the OHIO TAX ID NUMBER.

Part III ACH DEBIT OPTION (Please complete this section only if you select or are currently using this option)

Financial Institution Name

Type of Account

¨ Checking

¨ Savings

Transit & Routing Number

Bank Account Number

I hereby authorize the State of Ohio Treasurer’s Office to process ACH Debit entries from the bank account specified above. This debit

will pertain only to Electronic Funds Transfer Payments for the above named taxpayer.

Authorized Signature

Date

Part IV ACH CREDIT OPTION (Please complete this section only if you select or are currently using this option)

I hereby request the State of Ohio Treasurer’s Office to grant authority for the above named taxpayer to initiate ACH Credit Transactions

to the State Treasurer’s Office bank account. It is understood that these transactions must be in the NACHA CCD+ format using the

TXP Payment Convention and may only be initiated for the tax type specified above.

Authorized Signature

Date

MAIL: State Treasurer Joseph T. Deters

FAX : (614) 752-5377

Questions: Ohio State Treasurer’s Office

Attn: Electronic Payments Unit

EFT Help Line

30 East Broad Street, 9

Floor

(614) 752-8412

Print Form

Columbus, Ohio 43266-0421

1-877-EFT-OHIO

Revised 4/2000

Reset Form

Agreement Per Ohio Tax Id Number Form

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