Form Boe-555-St - Authorization Agreement For Electronic Funds Transfer (Eft) - State Of California
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2BOE-555-ST (FRONT) REV. 4 (2-05)
STATE OF CALIFORNIA
AUTHORIZATION AGREEMENT FOR
BOARD OF EQUALIZATION
ELECTRONIC FUNDS TRANSFER (EFT)
New EFT account
Please Check Appropriate Boxes:
Change EFT reporting method
Change bank account on
(date)
Change contact name or phone number
See reverse for instructions on completing this authorization agreement.
(Type or Print in Ink)
SECTION I
TAXPAYER NAME
BOE ACCOUNT NUMBER
DBA (Doing Business As)
BUSINESS PHONE NUMBER
(
)
CONTACT PERSON
CONTACT PHONE NUMBER
(
)
Complete Section II or III below:
SECTION II
ACH Debit
The State Board of Equalization is hereby authorized to initiate debit entries to the bank account identified below and the bank is authorized
to debit such account. This authority is to remain in full force until EFT payments are no longer required by statute or, until the State Board of
Equalization and I mutually agree to terminate my voluntary participation in the EFT program.
BANK NAME
BANK ACCOUNT NUMBER (not to exceed 17 digits)
Type of Account
Checking
TRANSIT AND ROUTING NUMBER
Savings
SIGNATURE OF TAXPAYER OR AUTHORIZED REPRESENTATIVE
TITLE OF SIGNER
DATE
PRINT NAME OF SIGNER AND CAPACITY IN WHICH SIGNED
IMPORTANT:
If you have selected the ACH Debit option, you must attach a voided check for the account to be debited. Your voided check
will verify bank account, transit and routing numbers. If you are unable to provide a voided check, a bank specification sheet
may be used instead of the voided check.
SECTION III
ACH Credit
The State Board of Equalization is hereby requested to grant authority for the above-named taxpayer to initiate ACH credit transactions to the
State Board of Equalization’s bank account. These payments must be in the NACHA CCD+ format using the Tax Payment Convention (TXP)
and may only be initiated for the EFT tax payments to the State Board of Equalization provided for by statute.
SIGNATURE OF TAXPAYER OR AUTHORIZED REPRESENTATIVE
TITLE OF SIGNER
DATE
PRINT NAME OF SIGNER AND CAPACITY IN WHICH SIGNED
Return this form to the section that administers the program for the above account:
Excise Taxes Section
Electronic Waste Recycling Fee Section
PO Box 942879
PO Box 942879
Sacramento, CA 94279-0056
Sacramento, CA 94279-0088
For EFT assistance, call 916-327-4208
For EFT assistance, call 916-341-6906
Fuel Industry Section
Environmental Fees Section
PO Box 942879
PO Box 942879
Sacramento, CA 94279-0030
Sacramento, CA 94279-0057
For EFT assistance, call 916-322-9669
For EFT assistance, call 916-322-9534
Make a copy for your records.
CLEAR
PRINT
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