Form R-20193-L - Authorization Agreement For Electronic Funds Transfer (Eft) Of Tax Payment Form 1999

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R-20193-L (2/99)
State of Louisiana
Department of Revenue
Authorization Agreement for
Electronic Funds Transfer (EFT) of Tax Payment
❏
❏
New Application
Change Document (effective date) ______________________
This section must be completed regardless of the payment method selected.
I
Taxpayer name
Revenue Account Number
Federal Identification Number
(if applicable)
Tax type - Enter the tax type name and the corresponding
5-digit NACHA Code from the instructions.
A separate authorization is required for each tax type.
Payment by EFT for this tax type is:
If voluntary: Requested effective tax period
❏
❏
Mandatory
Voluntary
Anticipated date of first transmission
(See restrictions in instructions.)
Contact person
Telephone
Contact person
Telephone
Mailing address for EFT purposes (street address, box number)
Mailing address (city, state, ZIP)
❏
ll
ACH Debit
I hereby authorize the Louisiana Department of Revenue to present debit entries into the bank account and the depository named
below. The individual debit transactions will be presented only after having been expressly authorized and initiated by the taxpayer.
These debits will pertain only to Electronic Funds Transfer payments that the taxpayer has initiated for payment of Louisiana taxes.
Signature
Title
Date
Bank name
Branch
Bank contact person
Telephone
Bank account number
Type of account
❏
❏
Checking
Savings
Transit and routing
Name on bank account
–
number
Please attach a copy of a voided check.
❏
lll
ACH Credit with Addenda
Before choosing the ACH Credit with Addenda option, check with your financial institution to be sure it can accommodate your needs.
❏
IV
Other Immediately Investible Funds
Cash or other guaranteed money must be delivered to the Department of Revenue in person or by courier on or before the due date
of the return. This does not include FedWire transfers.
Mail Application to:
For office use only.
Louisiana Department of Revenue
Effective tax period
Initials
EFT Processing
9800
P.O. Box 4018
Baton Rouge, LA 70821-4018

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