Form Eft-001 - Electronic Funds Transfer Authorization Agreement For Ach Credit Payment Method - 2007

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OFFICE USE ONLY
A
D
R
LABAMA
EPARTMENT OF
EVENUE
EFT Unit
Electronic Funds Transfer Authorization Agreement
for ACH Credit Payment Method
Form EFT: 001
2/07
P.O. Box 327950 • Montgomery, AL 36132-7950 • Telephone: 1-800-322-4106 • Fax (334) 242-0251
Taxpayer’s Name:
Address:
City / State / ZIP:
Tax Type:
Tax Account No.:
Tax Type:
Tax Account No.:
Tax Type:
Tax Account No.:
Tax Type:
Tax Account No.:
(
)
Contact Person:
Phone:
(
)
Title:
Fax:
Email:
Address:
IF YOU WISH TO REGISTER ADDITIONAL TAX ACCOUNTS,
ATTACH A SEPARATE SHEET GIVING THE TAX TYPE AND TAX ACCOUNT NUMBER.
I/we hereby agree to comply with the Department’s requirements for the ACH Credit Payment method. I/we also
authorize the Department to update our payment method to ACH Debit if I/we repeatedly fail to correctly complete the
payment transactions in accordance with the required procedures set forth by the Department.
Signature
Title
Date
Signature
Title
Date
Note: Taxpayers electing this payment method must provide a letter of justification. The form cannot be processed without
this information.

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