Looking for a Arizona Tax Forms And Templates? Download it for free!

DOR USE ONLY

Arizona Department of Revenue • EFT Unit

Mandatory

1600 West Monroe, Room 610 • Phoenix, AZ 85007-2650

Tel: (602) 716-7807 or 1-800-572-7037 • Fax: 1-602-716-7986

Voluntary

AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER AND DISCLOSURE AGREEMENT

Part I:

Taxpayer Information (required)

1 BUSINESS NAME

7 EFT CONTACT NAME

2 BUSINESS STREET ADDRESS 1

8 EFT CONTACT TITLE

3 BUSINESS STREET ADDRESS 2

9 BUSINESS PHONE NUMBER WITH AREA CODE

4 BUSINESS CITY

5 STATE 6 ZIP CODE

10 EFT CONTACT E-MAIL ADDRESS

Part II:

Tax Type/Payment Method and Agreement Information

Check and complete only each tax type/payment method that requires action. Check the box next to the applicable tax type and

payment method; ﬁ ll in the applicable taxpayer identiﬁ cation number.

Estimated Corporate Income Tax

Withholding (W/H) Tax

Transaction Privilege & Use Tax

EIN: _______________________

AZ State No: __________________

Modify existing account

W/H No.: ____________________

Part III: ACH Debit Option

(Complete this section only if you select or are currently using the debit option.)

Complete the requested information regarding the ﬁ nancial institution to be used. If payments are to be debited to the taxpayer’s

account, the form must be signed and dated by a person in the taxpayer’s organization who is an authorized signatory on the account

speciﬁ ed below. If payments are to be debited to a payroll service’s account, the form must be signed and dated by a person in the

payroll service’s organization who is authorized to enter into this agreement on behalf of the payroll service and is an authorized

signatory on the account speciﬁ ed below.

14 IF YOU WANT TO PAY VIA THE INTERNET,

15 ACCOUNT NAME

17 ACCOUNT NUMBER

PLEASE GO TO

AND SIGN UP THERE.

16 ACCOUNT TYPE

18 FINANCIAL INSTITUTION ROUTING/

TRANSIT NUMBER (ABA)

Checking

Savings

Part IV: ACH Debit Option

I hereby authorize the Arizona Department of Revenue to process debit entries from the bank account speciﬁ ed above. These

debits will pertain only to electronic funds transfer payments the above-named taxpayer or their agent initiates for payment of

the tax type(s) speciﬁ ed above.

Part V: ACH Credit Option

I hereby request that the Arizona Department of Revenue grant authority for the above-named taxpayer or their agent (Part I) to

initiate ACH credit transactions to the Department of Revenue bank account. It is understood that these transactions must be

in the NACHA CCD+ format using the Tax Payment Convention and may only be initiated for the tax type(s) speciﬁ ed in Part II.

Part VI: Disclosure Agreement

Check this box only if a third party not named on this form is being designated by the taxpayer indicated in Part I to receive

taxpayer conﬁ dential information from the Arizona Department of Revenue. By signing this form, the undersigned authorizes

the department to release conﬁ dential information relating to Arizona Department of Revenue Authorization Agreement and

Disclosure Agreement for Electronic Funds Transfer authorization to:

This Disclosure Agreement automatically revokes all earlier EFT authorization agreements and disclosure agreements on ﬁ le

with the Arizona Department of Revenue. Check this box if you do not want to revoke a prior EFT authorization agreement

and disclosure agreement. You MUST attach a copy of any prior agreements you want to remain in effect.

This form is not a Power of Attorney and does not grant the contact person(s) any power of representation. This disclosure

authorization is to remain in force until rescinded by the undersigned. By signing this form, I certify that I have the authority to execute

this authorization form on behalf of the above-mentioned corporation(s), limited liability company(ies), trust(s), partnership(s), and/or

individual(s).

Taxpayer’s Authorized Signature

Title

Date

Payroll / Accounting Service Group’s Authorized Signature

Title

Date

NOTE: This form may be duplicated. Please make a copy for future use.

ADOR 11-2056 (3/05)

Form Ador 11-2056 - Authorization Agreement For Electronic Funds Transfer And Disclosure Agreement

Related Articles

Related forms

Related Categories