Form Eft-1 - Authorization Agreement For Electronic Funds Transfer
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1EFT-1
Department of Revenue Services
Connecticut Tax Registration Number
State of Connecticut
25 Sigourney Street
Authorization Agreement for
Tax Type
Hartford CT 06104-2937
Electronic Funds Transfers
(Rev. 10/04)
See back for instructions
Enter company name and mailing address
Please Print or Type
All taxpayers must complete this section.
(
)
Primary EFT Contact Person: ____________________________________________________________________________________________
A
Telephone Number
Address: ____________________________________________________________________________________________________________
Street
City
State
ZIP Code
Payment Options - Choose one payment option
Automated Clearing House (ACH) Debit Option - Complete this section only if you choose the ACH Debit Option
You are authorizing the Connecticut Department of Revenue Services (DRS) to present debit entries to your bank for the tax identified above.
Confirm your bank account number and routing/transit number with your bank representative.
Bank Name: __________________________________________________________________________________________________________
Bank Address: _______________________________________________________________________________________________________
Street
City
State
ZIP Code
Bank Account Number: ________________________ Bank Routing/Transit Number: ________________________
Checking
Savings
(
)
Print Name of Bank Representative
Telephone Number
Taxpayer Signature (Owner, Partner, or Corporate Officer)
Title
Date
B
Sales and use tax, business use tax, and room occupancy tax filers only, check one of the following:
I will use DRS Fast-File to file my tax returns and to pay any taxes due. (Taxpayers that participate in the NY/CT
agreement may not use Fast-File.)
I will use DRS Fast-File to file my tax returns and will initiate my payments using the DRS Service Bureau.
I will file paper tax returns and will initiate my payments using the DRS Service Bureau. (Voluntary EFT filers and
taxpayers that participate in the NY/CT agreement only)
Withholding filers only, please check one of the following:
I will use DRS Fast-File to file my coupons and quarterly reconciliations and to pay any taxes due.
I will initiate my coupon payments using the DRS Service Bureau.
Corporation business tax filers only, please check one of the following:
I will use DRS Fast-File to make my estimated corporation business tax payments.
I will initiate my estimated corporation business tax payments using the DRS Service Bureau.
ACH Credit Option - Complete this section only if you choose the ACH Credit Option
Confirm with your bank representative that you and your bank are capable of initiating ACH credits in the required CCD+TXP format.
Bank Name: __________________________________________________________________________________________________________
C
Bank Address: _______________________________________________________________________________________________________
Street
City
State
ZIP Code
(
)
____________________________________________________________________________________________________________________
Print Name of Bank Representative
Telephone Number
____________________________________________________________________________________________________________________
Taxpayer Signature (Owner, Partner, or Corporate Officer)
Title
Date
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