Form Wv/eft-5 - Electronic Funds Transfer Application
ADVERTISEMENT
1West Virginia State Tax Department
WV/EFT-5
REV. 03/10
Change Payment
Electronic Funds Transfer Application
Type
New
Change Taxpayer
Change Name
Change Bank
Change Bank Transit
Withdrawl
Application
ID Number
or Address
Account No.
or Routing No.
A
TAXPAYER ID
C
C
BUSINESS NAME
O
U
N
ADDRESS*
T
C
EFT Contact Person:
O
N
Address:
T
A
C
Telephone: (
)
E-Mail:
T
Complete Either Debit Section or Credit Section
ACH Debit - Taxpayer initiates payments on-line or through the West Virginia Tax Department Pay-by-Phone System
I hereby authorize the State of West Virignia, hereinafter called STATE, to initiate debit entries and to initiate, if necessary credit entries as adjustments for
any entries in error into my bank account indicated below and the Financial Institution named below, hereinafter called DEPOSITORY, to debit the same
any amount(s) owed by me to the State of West Virignia. This authority is to remain in full force and effect until STATE has received written notification from
me of its termination in such time and in such manner as to afford STATE and DEPOSITORY a reasonable opportunity to act on it.The use of an EFT PIN
will be required to convey my instructions for each transaction. The EFT PIN may be used by me or by my agent.
Transit/Routing Number (See Reverse)
Type of Account:
Checking
Bank Account Name
Bank Account Number
Savings
Title
Date
Authorized Signature
*A voided check for the bank account indicated above MUST accompany this application
ACH Credit - Taxpayer initiates through own bank
I have contacted my bank and confirmed the bank can initiate Automated Clearing House credit transactions that meet West Virginia State Tax
Department requirements. For verification the West Virginia State Tax Department may contact:
Name of Bank
I hereby request the West Virginia State Tax Department grant authority for the above named taxpayer to initiate Automated Clearing House
transactions to the State of West Virginia's electronic funds transfer account. I understand these must be in the NACHA CCD+ format using the
Tax Payment (TXP) Convention and may only be initiated for the tax types that have been registered for EFT payments with the West Virginia
State Tax Department.
Date
Authorized Signature
Title
*West Virginia does not accept electronic payments originating outside the United States
Mail completed application to: WV STATE TAX DEPT., RD-EFT, PO BOX 11895, CHARLESTON WV 25339-1895
OR FAX TO (304) 558-8604
TO FILE AND PAY WEST VIRGINIA TAXES ON LINE CLICK THE MYTAXES.WVTAX.GOV LINK ON OUR WEB SITE WVTAX.GOV
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial