Form Dr-600a - Enrollment And Authorization For E-Services Program

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DR-600A
Enrollment and Authorization for e-Services Program
R. 04/11
Section 1 – Check the Box That Applies
Initial enrollment
Change in filing/payment method
Bank change
Contact information change
Complete all sections
Complete sections 2, 4, 5, and 6
Complete sections 2, 5, and 6
Complete sections 2, 3, and 6
Section 2 – Business Information
Business entity name
Type of remittance/fee
FEIN
License/Permit/Agency number (if different from FEIN)
Physical address
City/State/ZIP
Telephone number (include area code)
Fax number (include area code)
Check Entity Type:
Corporation (check type)
C Corp
S Corp
Partnership (check type)
General
Limited
Joint Venture
Limited Liability Company (check type)
Single Member
Multi-member
Sole Proprietorship
Business Trust
Governmental Agency
Section 3 – Contact Information
Electronic Payment Contact Person’s Information
Name
Mailing address
City/State/ZIP
Telephone number (include area code)
Fax number (include area code)
E-mail address
Section 4 – Fee/Remittance Type Payment Method Selection
Locate the remittance or fee type, select the payment method you intend to use, and check the appropriate box.
Type of Remittance or Fee
EFT only (ACH-Debit)
EFT only (ACH-Credit)*
DMS - Florida Retirement System contributions
DMS - Division of State Group Insurance premiums (universities)
BPR - Tobacco fees
BPR - Beverage fees
BPR - Pari-mutuel taxes and fees
BPR - Pari-mutuel slot receipts and fees
BPR - Pari-mutuel card room receipts and fees
*You must supply a letter that states a valid business reason for selecting the ACH-Credit payment method. Valid reasons include your previous use
of this method in other business-related activities, or internal controls within your business regarding ACH transfers.

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