Form 90-302 - Iowa Motor Fuel Tax Authorization Agreement For Electronic Funds Transfer (Eft)

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Iowa Department of Revenue
Iowa Motor Fuel Tax Authorization Agreement
for Electronic Funds Transfer (EFT)
Please PRINT your company name and address:
_____________________________________
Tax Type: ______________________________________
_____________________________________
Tax ID Number: __________________________________
_____________________________________
OFFICE USE ONLY
_____________________________________
MVF License Number: ____________________________
METHOD OF PAYMENT: check only one of the following:
ACH Debit (not available for LPG)
ACH Credit
If you selected
If you selected the ACH credit option, proceed to the EFT
the ACH debit
contact person section. Please complete all information there.
option, proceed
We will contact you about depositing bank account numbers.
to line 1.
1. Routing Transit Number (RTN):
(You will find these numbers between the symbols 1: and 1: at the bottom left of your check.
This is a 9 digit number.)
2. Your financial institution account number:
3. Type of Account:
Savings
Checking
4. Password (mandatory security feature) of your choosing: __ __ __ __
Use four numeric digits.
This form authorizes the Iowa Department of Revenue to process variable EFT entries to your account, but only by
your initiation. To stop EFT, you must notify the department in writing.
EFT Contact Person (please print): ___________________________________________ DATE: _________________
Mailing Address of Contact Person: __________________________________________________________________
Fax Number: _______________________________
Telephone Number: ________________________________
E-mail Address: ________________________________
If a tax service will be making your payments, please complete the following information:
Tax Service Name: _______________________________________________________
Tax Service Address: _____________________________________________________
Fax Number: _______________________________
Telephone Number: ________________________________
E-mail Address: ________________________________
Complete this form and return with your Application
for Motor Fuel Tax License (form #80-001) to:
Compliance Division, Fuel Tax Unit
You will receive a detailed EFT information booklet
Iowa Department of Revenue
describing both options.
P.O. Box 10456
Des Moines, IA 50306-0456
90-302 (12/19/05)

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