Form 10a070 - Authorization Agreement For Electronic Funds Transfer

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10A070 (1-05)
K
D
R
ENTUCKY
EPARTMENT OF
EVENUE
A
A
F
E
F
T
UTHORIZATION
GREEMENT
OR
LECTRONIC
UNDS
RANSFER
Taxpayer name
Please check appropriate box
New EFT account
Mailing address (street, apartment, route)
Change EFT method**
Change bank account
Mailing address (street, apartment, route)
Change contact name
and/or address
Add tax types*
Mailing address (city, state, zip)
Federal Identification Number
Taxes to be paid using EFT
Tax Type Code Kentucky ID Number
Contact name
Phone Number Fax Number
____________ ____________________ __________________________________ ____________ _____________
____________ ____________________ __________________________________ ____________ _____________
____________ ____________________ __________________________________ ____________ _____________
*If you are volunteering tax types to be paid using EFT, please indicate an * next to the tax type code above.
**Last payment date under old ACH method ___ / ___ / ___ .
ACH Debit—taxpayer initiates through the Department of Revenue
I authorize the Kentucky Department of Revenue to initiate debit entries to the above-named taxpayer’s
account(s). This authority will remain in effect until the department has received written notification of its
termination at least 30 days prior to the effective date. (Must complete bank information below.)
Bank name
Phone number
Bank account number (not to exceed 17 digits)
Type of account:
savings
checking
Routing and transit number (requires 9 digits)
Authorized signature
Date
ACH Credit—taxpayer initiates through own bank
I hereby request the Department of Revenue to grant authority for the above-named taxpayer to initiate
Automated Clearing House credit transactions to the department’s bank account. I understand these must be
in the NACHA CCD+ format using the TXP convention and may only be initiated for the tax types listed above.
Failure by the taxpayer to include a suitable TXP convention with the payment will result in a delay to proper
posting of credit.
Authorized signature
Date
Do you want to receive ACH credit payment confirmations?
Yes
No
Return top copy to:
Kentucky Department of Revenue, Electronic Commerce, P .O. Box 181, Station 23,
Frankfort, Kentucky 40602-0181
Phone: 1-800-839-4137
Fax: (502) 564-6842

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