Form Eft-1 - Authorization Agreement Form For Electronic Funds Transfer - 2005

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EFT-1
INDIANA DEPARTMENT OF REVENUE
State Form 50110
AUTHORIZATION AGREEMENT FORM
R4 /11-05
FOR ELECTRONIC FUNDS TRANSFER
DATE:
INDIANA TAXPAYER ID #: ________________________________
(MUST BE 13 DIGITS)
See Special Instructions on Back.
Business Name:
Name and Telephone Number of Individual in your Organization that Revenue may contact regarding EFT:
Contact Person:
(Please print)
(Not a Bank contact)
EFT Required
Address:
or
City, State, Zip:
Voluntary
Telephone:
FOR TAX TYPE:
Please complete a separate form for each Tax Type selected
Sales (RST)
Financial Institution (FIT)
Tire Fee (TIF)
Utility Receipts Tax (URT)
Withholding (WTH)
Gasoline Distributors (MFT)
Prepaid Sales on Gasoline (PPD)
Special Fuel Tax (SFT)
Corporate Income (COR)
Streamlined Sales Tax (SST)
Please choose an EFT method. If you choose ACH Debit, you must also complete the banking information portion of this form, as well as attach a copy
of a voided check to verify the banking information.
ACH Debit* (Complete bank information)
Checking
or
Savings
ACH Credit
Bank ABA#: _________________________________
(Transit Routing Number)
Your Account #: ______________________________
(With the above bank)
________________________________________________
______________________
__________________
Authorized Signature
Title
Date
*If ACH Debit is chosen, the taxpayer hereby authorizes the Indiana Department of Revenue to present debit entries into the
bank account referenced above as required by Indiana Law. These debits will pertain only to Electronic Funds Transfer
payments that the taxpayer has initiated.
EFT Section
This form may be faxed or mailed.
Indiana Department of Revenue
Fax # ................. (317) 615-2691
P.O. Box 6076
Questions? ....... (317) 615-2695
Indianapolis, IN 46206-6076

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