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Iowa Authorization Agreement
Iowa Department of Revenue
for Electronic Funds Transfer (EFT)
by ACH Credit
This form authorizes the Iowa Department of Revenue to process
variable EFT entries to your account, but only by your initiation.
Please PRINT your company name and address:
_____________________________________
Tax Type: ______________________________________
_____________________________________
_____________________________________
Tax ID Number: __________________________________
_____________________________________
ACH Credit is available for the following Tax Types:
Consumer’s Use Tax
Sales Tax
Retailer’s Use Tax
Corporation Tax
Motor Fuel Tax
Withholding Tax
Please complete all information in the EFT CONTACT PERSON section. The Iowa Department of Revenue
will contact you with additional instructions after your authorization agreement has been processed.
EFT CONTACT PERSON
EFT Contact Person (please print): ____________________________________ DATE:________________
Mailing Address of Contact Person: __________________________________________________________
Telephone Number: ___________________________ Fax Number: _______________________________
E-mail Address: ________________________________
If a tax service will be making your payments, please complete the following information:
Tax Service Name: ______________________________________________________
Tax Service Address: ____________________________________________________
Telephone Number: ___________________________ Fax Number: _______________________________
E-mail Address: ________________________________
Complete this form and send it to:
or fax it to:
or e-mail it to:
EFT Registration
515/281-5830
idreft@iowa.gov
Iowa Department of Revenue
PO Box 10413
Des Moines IA 50306
92-116 (9/21/06)
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