Authorization Agreement For Electronic Funds Transfer (Eft) Of Unemployment Tax Payments Form

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STATE OF LOUISIANA
DEPARTMENT OF LABOR
AUTHORIZATION AGREEMENT FOR
ELECTRONIC FUNDS TRANSFER (EFT)
OF UNEMPLOYMENT TAX PAYMENTS
(CHECK ONE)
NEW APPLICATION
CHANGE IN INFORMATION
CANCEL AGREEMENT
This document is semi interactive. Fill it out online and mail it back to address noted below.
EMPLOYER NAME
STATE U.I. NUMBER
FEDERAL I. D. NUMBER
1ST CONTACT PERSON
TELEPHONE NUMBER
2ND CONTACT PERSON
TELEPHONE NUMBER
Mailing address for EFT purposes (Street address, PBX number)
Signature is required regardless of payment option selected.
SIGNATURE.
TITLE
DATE
(CHOOSE ONE)
ACH DEBIT AUTHORIZATION AGREEMENT
ACH CREDIT WITH ADDENDA RECORD
I hereby authorize the Louisiana Department of Labor to present debit entries into the bank account and the depository named below.
The individual debit transaction will be presented only after having been expressly authorized and initiated by the employer. These
debits will pertain only to Electronic Funds Transfer Payments that the employer has initiated for payment of Louisiana Unemployment
Taxes. I may revoke my authorization at any time by writing to the address noted below.
FOR ACH DEBIT AUTHORIZATION ONLY
BANK NAME
BRANCH
TELEPHONE NUMBER
BANK CONTACT PERSON
NAME ON BANK ACCOUNT
BANK ACCOUNT NUMBER
TYPE OF ACCOUNT
CHECKING
SAVINGS
TRANSIT AND ROUTING
NUMBER
PLEASE ATTACH A COPY OF VOIDED CHECK FOR VERIFICATION
MAIL APPLICATION TO:
FOR OFFICE USE ONLY
EFFECTIVE DATE
Louisiana Department of Labor
Office of Management & Finance
EFT Processing - Cashiering Unit
P O Box 94186
Baton Rouge, LA 70804-9186

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