Form 10a070 - Authorization Agreement For Electronic Funds Transfer - 2008
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110A070 (1-08)
AUTHORIZATION AGREEMENT
Commonwealth of Kentucky
FOR ELECTRONIC FUNDS TRANSFER
DEPARTMENT OF REVENUE
New EFT account
Change EFT method**
Changed contact name and/or address
Taxpayer Information
Bulk Tax Filer Information
Taxpayer name
Bulk Tax Filer Name
____________________________________________
_____________________________________________
Contact name
Contact Name
____________________________________________
_____________________________________________
Mailing address (street, apt., route)
Mailing address (street, apt.,route)
____________________________________________
_____________________________________________
Mailing address (street, apt., route)
Mailing address (street, apt., route)
____________________________________________
_____________________________________________
City, State, Zip
City, State, Zip
____________________________________________
_____________________________________________
Phone number
Fax number
Phone number
Fax number
____________________________________________
_____________________________________________
E-mail Address
E-mail Address
____________________________________________
_____________________________________________
Taxes to be paid using EFT:
Tax Type Code
KY ID Number
Business Name
FEIN
/
/
**Last payment date under old ACH Method
ACH Debit - taxpayer initiates through the Department of
ACH Credit - taxpayer initiates through own bank
Revenue
I authorize the Kentucky Department of Revenue (DOR) to initiate debit
I hereby request DOR to grant authority for the above-named taxpayer
entires to the above-named taxpayer’s account(s). This authority will
to initiate Automated Clearing House credit transactions to DOR’s bank
remain in effect unitil DOR has received written notification of its
account. I understand these must be in the NACHA CCD+ format using
termination at least 30 days prior to the effective date. (Must complete
the TXP conventon and may only be initiated for the tax types listed
bank information below.)
above. Failure by the taxpayer to include suitable TXP convention with
payment will result in a delay to proper posting of credit.
____________________________________________
Bank name
Phone Number
____________________________________________
_____________________________________________
Bank account number (not to exceed 17 digits)
Authorized Signature
Date
____________________________________________
Bank routing and transit number (requires 9 digits)
Type of Account
checking
savings
____________________________________________
Authorized Signature
Date
Return copy to: Kentucky Department of Revenue, Electronic Commerce, P.O. Box 181, Station 21,
Frankfort, KY 40602-0181
Phone 1-800-839-4137
Fax: (502) 564-6842
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