Form Eft-1 - Authorization Agreement Form For Electronic Funds Transfer - Indiana Department Of Revenue

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EFT-1
Indiana Department of Revenue
State Form 50110
Authorization Agreement Form
(R11 / 9-14)
For Electronic Funds Transfer
Indiana Taxpayer Identification Number: ___________________
Date: ______________
(Must be 13 digits; see special instructions on back.)
Business Name: __________________________________________________
Name and Telephone Number of Individual in Your Organization that Revenue May Contact Regarding EFT:
Contact Person: __________________________________________________
(Not a bank contact)
(Please print)
Address: ________________________________________________________
City, State, ZIP Code: _____________________________________________
Telephone Number: _______________________________________________
Please complete a separate form for each tax type selected.
o
o
o
County Innkeepers (CIT)
Corporate Income (COR)
Financial Institution (FIT)
o
o
o
Gasoline Use (GUT)
Motor Fuel Use (MFT)
Sales (RST)
o
o
o
Special Fuel (SFT)
Streamlined Sales (SST)
Tire Fee (TIF)
o
o
o
Type II Gaming (TTG)
Utility Receipts (URT)
Wireless Prepaid 911 Fee (WPC)
o
Withholding (WTH)
Please choose an EFT method. If you choose ACH Debit, you must also complete the banking information portion of this
form and attach a copy of a voided check to verify the banking information.
o
o
ACH Credit
ACH Debit* (Complete bank information)
Do not use this form to register for INtax. Visit
Bank ABA Number: _____________________
(transit routing number)
o
o
Checking
or
Savings
Will the funds for the ACH Debit payments come
Your Account Number: ___________________
from a bank outside of the United States?
(With the above bank)
o
o
No
Yes
If yes, the EFT Section will contact you.
_________________________________________
___________________
______________
Authorized Signature
Title
Date
*If ACH Debit is chosen, the taxpayer hereby authorizes the Indiana Department of Revenue to present debit entries
into the bank account referenced above as required by Indiana law. These debits will pertain only to electronic funds
transfer payments that the taxpayer has initiated.
This form may be faxed or mailed.
Indiana Department of Revenue
Fax: (317) 232-1851
EFT Section, Room N248, MS 103
Questions: (317) 232-5500
100 N. Senate Ave.
Indianapolis, IN 46204-2253

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