Form: Ef-App1 - Electronic Filing Application - Indiana Department Of Revenue

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INDIANA DEPARTMENT OF REVENUE
Form: EF-APP1
ELECTRONIC FILING APPLICATION
Date:____________
Revised 2/02.
Indiana TID# (13 digits): ____________________ DUNS:______________ FEIN:______________
Taxpayer/Company Name :__________________________________________________________
Address: ________________________________________________________________________
City, State, Zip: ___________________________________________________________________
Electronic Filing Contact Name: __________________________________Ph. _________________
Sales Contact Name:___________________________________________Ph. _________________
Withholding Contact Name:______________________________________Ph. _________________
The taxpayer identified above, understanding and accepting the stipulations presented on the reverse
side, hereby applies for authorization to transmit data to the Department of Revenue electronically in
accordance with the department’s electronic filing program as set forth in the Electronic Filing
I
nformation Guide dated: ___/___/___.
Authorized Signatures:
_____________________________________
____________________________________________
Printed:
Written:
_____________________________________
____________________________________________
Printed:
Written:
_____________________________________
____________________________________________
Printed:
Written:
Communications Method: (Check One)
1. I will use IN-S.I.T.E. software and I will download it from the Departments web site. ________
2. I will use IN-S.I.T.E. software and I will require diskettes from the Department.
________
3. I will use other software which has been approved by the Department.
________
4. Our response to your application can be faxed to you. Enter your fax number here: ________
Signatures on the application authorize the Indiana Department of Revenue to present debit entries into
specified accounts for electronic funds transfer as required by Indiana Law.
Mail to: Electronic Commerce – Business Taxes
FAX to: 317-615-2691
P. O. Box 6076
Indianapolis, IN 46206-6076
E-mail:____________________________
PLEASE READ THE NEXT PAGE
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