Form E-Ach.slb - 2007 - Arizona Licensed Surplus Lines Broker (Firm) Registration For Ach Tax Payments - Department Of Insurance State Of Arizona

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DEPARTMENT OF INSURANCE
STATE OF ARIZONA
Financial Affairs Division – Tax Unit
th
2910 North 44
Street, Suite 210
Phoenix, Arizona 85018-7269
Phone: (602) 364-3998
Fax: (602) 364-3989
Arizona Licensed Surplus Lines Broker (Firm)
Registration for ACH Tax Payments
A firm that holds an Arizona Surplus Lines Broker license and chooses to remit semi-annual Surplus Lines Tax payments via
ACH delivery must complete and return this form.
If you have any questions, contact:
Kelly Stephens, Compliance Section Manager at
kstephens@azinsurance.gov
or (602) 364-3964.
This form must be completed and returned to (received by) the Department at the address shown above before ACH
payments commence. Participants MUST follow the file setup instructions in form E-ACH.INSTRUCTION exactly.
Does this firm wish to send a $0.01 pre-note prior to its first tax
ARIZONA LICENSE #
FEIN #
payment?
YES
NO
If YES, indicate anticipated setup date for $0.01 test:
FIRM NAME:
MAILING ADDRESS:
Contact Person:
Address
Contact Telephone #:
City
State
Zip
Contact E-Mail:
X
Signature of Officer
Date
X
Name And Title (Type Or Print)
E-ACH.SLB (12/07)
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