Form Eft-1 - Authorization Agreement For Electronic Funds Transfer
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Illinois Department of Revenue
EFT-1
Authorization Agreement for Electronic Funds Transfer
Step 1: Check the reason you are completing Form EFT-1
Initial set up
Change(s) to previously submitted information*
Effective date of change:____/____/________
_____________________________________________________________________
*Specify change
Step 2: Identify the taxpayer
1
3 ___ ___ - ___ ___ ___ ___ ___ ___ ___
_________________________________________________
Taxpayer’s name
Federal employer identifi cation number (FEIN)
2
4 ____________ - ___________
_________________________________________________
Address
Illinois account number
5 ___ ___ ___ - ___ ___ - ___ ___ ___ ___
_________________________________________________
Social Security number (SSN)
City
State
ZIP
Step 3: Complete designated agent information
- Only if a designated agent will be making payments.
6
8
_________________________________________________
_________________________________________________
Contact person’s name
Designated agent’s name
7
9
_________________________________________________
(_____)_________________
(_____)_________________
Address
Telephone
Fax
10
_________________________________________________
_________________________________________________
City
State
ZIP
Signature authorization for EFT Program (Authorized offi cer of designated agent)
Step 4: Identify your EFT contact person
11
13
_________________________________________________
(_____)_________________
(_____)_________________
Contact person’s name - Please print
Telephone
Fax
12
_________________________________________________
E-mail address
Step 5:
Check your ACH option
Debit
Credit
(telephone system only) - see instructions
- Go to Step 6.
Business
Individual/Consumer
or
14
17
_________________________________________________
Account type:
Financial institution’s name
Checking
or
Savings
15
_________________________________________________
Name on account
16
18 ___ ___ ___ ___ ___ ___ ___ ___ ___
_________________________________________________
Account number
Routing transit number
Step 6: Check the authorized payments
Business income tax
IL-1120-ES
IL-1023-CES
Electricity dist. & invested capital
ICT-1
ICT-4
IL-505-B
IL-1120**
Gas revenue and gas use tax
RPU-50
RG-1
**IL-1120 annual payments can only be made by ACH credit or internet
Withholding income tax
IL-501
IL-941
Electricity excise tax
RPU-50
RPU-13
Individual income tax
IL-1040-ES
IL-505-I
Telecom taxes - state & local
RPU-50
RT-2
Sales, service and use tax
RR-3
ST-1
Telecom infrastructure maint. fee
RT-10
Motor vehicle renting tax
ART-1
Tobacco products tax
TP-1
Chicago soft drink tax
ST-14
Cigarette tax (ACH debit option only)
RC-1-A
County motor fuel tax
CMFT-1
Hotel tax
RHM-1
MPEA food & beverage tax
ST-4
Liquor tax
RL-26
26-A
Prepaid sales tax (motor fuel)
PST-3
PST-1
Liquor airline tax
RL-
Step 7: Sign and complete
Under penalties of perjury, I state that I have examined this form and to the best of my knowledge it is true, correct, and complete. The Illinois
Department of Revenue is authorized to use this information in accordance with the Department of Revenue Law of the Civil Administrative
Code of Illinois and all applicable Illinois tax acts. This agreement shall remain in force until the department receives written notifi cation from
the taxpayer.
_________________________________________________
_______________________
____/____/________
Signature of taxpayer, authorized offi cer, or partner
Title
Date
EFT-1 (R-9/09)
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Parent category: Financial