Registration To Pay Dua Taxes Via Ach Credit Form

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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT (EOLWD)
DIVISION OF UNEMPLOYMENT ASSISTANCE (DUA)
REGISTRATION TO PAY DUA TAXES VIA ACH CREDIT
Company Name: __________________________________________________________
DUA Employer Number: ____________________________________________________
Federal Identification Number: _______________________________________________
Agent / PTP / Third Party?
Yes
No
Agent ID Number _________________
Street: _________________________________________________________________
City / State: __________________________________ Zip Code: _________________
Contact Person(s): ________________________________________________________
Email Address: _______________________________
Telephone Number(s): _________________________
Fax Number: _________________________________
Your Signature:_________________________________ Title:_________________________
Mail Form To:
Division of Unemployment Assistance
th
Attn.: Carlos DaSilva, Revenue Service, 5
Floor
19 Staniford Street
Boston, MA 02114
Or
Fax To: 617-523-2334
After submittal of this registration, you will be provided with the DUA mandated ACH credit
record layout and DUA bank account and routing transit numbers.
06/02/10

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