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Form Eft-002 - Taxpayer Registration/authorization Form - Georgia Department Of Revenue

EFT-002 (Rev 8/12)

GEORGIA EFT

ACH-CREDIT

Taxpayer Registration/Authorization Form

1. Taxpayer Name:_______________________________ Client ID(If 3

party vendor) ______________

2. Address: ________________________________________________________________________

City: _________________________________________________ State: _____ ZIP: ___________

3. State Taxpayer ID#’s (Required): STI _________________________ FEIN ____________________

4. Type of Tax Payment (Check one per Request):

[

] WH [

] Non-Res WH [

] ST [

] Corp [

] 911 Wireless

5. Taxpayer’s Contact Person: _________________________________ Title: _____________________

Phone: ________________ Ext: ______________ Fax: ________________

e-Mail(required):_____________________________________________________________

6. 3

Party Contact For GA Returns & Payments: ___________________________________________

Phone: ________________ Ext: ______________ Fax: ________________

e-Mail(required): _______________________________________________________________

7. I/We attest that to the best of my/our knowledge the above information is correct and I/we are set up to

use the credit method of electronically transferring tax payments.

Signature _____________________ Title: ________________________ Date: ________________

(Taxpayer)

Signature _____________________ Title: ________________________ Date: ________________

Party Vendor)

Please scan and return by e-Mail to

DOR.ElectronicFundsTransfer@dor.ga.gov

Fax to (404) 417-4317

Georgia Department of Revenue

Taxpayer Services Division

Form Eft-002 - Taxpayer Registration/authorization Form - Georgia Department Of Revenue