Form Dr-600a - Enrollment And Authorization For E-Services Program (Page 2 of 2) in pdf

DR-600A

R. 04/11

Page 2

Section 5 – Banking Information (not required for ACH-Credit)

Bank Name _________________________________________ ABA Routing/Transit No.

Bank Account No. _ __________________________________

Account Type

Business Checking

Personal Checking

Business Savings

Personal Savings

Note: Due to federal security requirements, we cannot process international ACH transactions. If any portion of the

money used in payments you will make will come from financial institutions located outside of the US or its territories

for the purpose of funding these payments, please contact us to make other payment arrangements. If you are unsure,

please contact your financial institution.

Section 6 – Enrollee Authorization and Agreement

This is an Agreement between the Florida Department of Revenue, hereinafter “the Department,” and the business entity

named herein, hereinafter “the Enrollee,” entered into according to the provisions of the Florida Statutes and the Florida

Administrative Code.

By completing this agreement and submitting this enrollment request, the Enrollee applies and is hereby authorized

by the Department to make tax and fee payments, and transmit remittances to the Department electronically. This

agreement represents the entire understanding of the parties in relation to the electronic transmission of tax and fee

payments.

The same statute and rule sections that pertain to all manual payments made by the Enrollee also govern a payment

made electronically according to this enrollment.

I certify that I am authorized to sign on behalf of the business entity identified herein, and that all information provided in

this document has been personally reviewed by me and the facts stated in it are true. According to the payment method

selected above, I hereby authorize the Department to present debit entries into the bank account referenced above at

the depository designated herein (ACH-Debit), or I am authorized to register for the ACH-Credit payment privilege and

accept all responsibility for the filing of payments through the ACH-Credit method.

_________________________________________________________________

______________________________

_____________________________

Signature

Title

Date

_________________________________________________________________

______________________________

Print Name

Telephone Number

_________________________________________________________________

______________________________

_____________________________

Second signature (if dual signature account)

Title

Date

Complete and mail this form to:

e-Services Unit

Call for assistance:

Florida Department of Revenue

800-352-3671

PO Box 5885

Tallahassee FL 32314-5885

Fax 850-922-5088

Form Dr-600a - Enrollment And Authorization For E-Services Program Page 2

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