Electronic Payment System Authorization Form

State of Nevada

Department of Employment, Training & Rehabilitation

Nevada Unemployment

Insurance Electronic

Payment System

ELECTRONIC

PAYMENT SYSTEM AUTHORIZATION

FORM

New EPS Reporter

D

Change Bank Account Number D

Change Contact name, address, and/or phone number D

Unem 10 ment Insurance Account to be credited:

FEIN

#

Multiple Accounts? OYes ONo

Agent OYes ONo

Contact Person

~Title

Company Narn~

Complete Address

Telephone Number (

)

Ext.

e-mail address

I/we hereby authorize the Department of Employment, Training & Rehabilitation to initiate ACH debit entries into the bank account referenced below and credit the Nevada

Unemployment Insurance Account named above. These debits will pertain only to Electronic Funds Transfer Payments that the taxpayer has initiated for payment to the

Nevada Employment Security Division.

I understand that I must request any changes or terminations to my Electronic Payment account in writing. All requests must be

directed to the address listed below. Transactions completed on state holidays, weekends, or after 5 :00 p.m. Pacific Time will not be processed until the next regular business

day. Debits not honored by taxpayer's banking institution due to insufficient funds are subject to a $25.00 fee. Any questions may be directed to the Electronic Payment

Customer Service Desk at (775) 687-3514 or visit our website at

Authorized Signature

Title

Date

Title

Date

Authorized Signature

Please complete this form and return to:

State of Nevada

Department of Employment, Training & Rehabilitation

Employment Security Division, Contributions

Section

500 East Third Street

Carson City, NV 89713-0030