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Wyoming Sales/use Internet Filing Service Electronic Agreement Form - Wyoming Department Of Revenue (2006) Page 3

Wyoming Sales/Use Internet Filing Service Electronic Agreement

Page 3

VIII

Authorization for E-CHECK Payment Transfer

Taxpayer:_________________________________________________________

Wyoming Sales/Use Tax Number:_______________

Bank Information

Bank Name:__________________________________________________________________

Bank Street Address: __________________________________________________________

__________________________________________________________

Routing Number:

________________________________________________________

Account Information

Account Name:

__________________________________________________________

Account Number:

__________________________________________________________

Account Type:

__________________________________________________________

Please return the signed original contract to

Sales/Use Tax Division Contact:

Attention: Vendor Operations Section

Excise Tax Division, Wyoming Department of Revenue

122 West 25

Street

Cheyenne, WY 82002-0110

This agreement represents the entire and integrated agreement between the parties (all taxpayers must

sign) Your Login, Password and PIN will be e-mailed to our contact person unless otherwise

instructed.

X_______________________________________________________________

Taxpayer

Date

X_______________________________________________________________

Department of Revenue

Date

See Page 4 for contact phone numbers:

H:\Web\WYIFS_agreement_Excise_Form10.doc

Revised 04/25/06

Wyoming Sales/use Internet Filing Service Electronic Agreement Form - Wyoming Department Of Revenue (2006) Page 3