Form 92-116 - Iowa Authorization Agreement For Electronic Funds Transfer (Eft) - 2005

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Iowa Department of Revenue
Iowa Authorization Agreement
for Electronic Funds Transfer (EFT)
This form authorizes the Iowa Department of Revenue to process
variable EFT entries to your account, but only by your initiation.
To stop EFT, you must notify the department in writing.
Please PRINT your company name and address:
_____________________________________
_____________________________________
Tax Type: ______________________________________
_____________________________________
Tax ID Number: __________________________________
_____________________________________
Effective Date: ___________________________________
METHOD OF PAYMENT: Check only one of the following
ACH Debit is available for:
ACH Credit is available for:
Sales Tax
Sales Tax
Corporation Tax
Corporation Tax
Motor Fuel Tax
Motor Fuel Tax
This option is not available for withholding tax.
Withholding Tax
Direct debit is available for withholding tax through the
If you selected the ACH credit option,
eFile & Pay system only.
proceed to the EFT CONTACT PERSON section.
Please complete all information there. We will contact you
If you selected the ACH debit option,
about depositing bank account numbers.
proceed to BANK INFORMATION.
BANK INFORMATION: Complete if you chose ACH Debit
1. Routing Transit Number (RTN):
(You will find these numbers between the symbols 1: and 1: at the bottom left of your check.
This is a 9 digit number.)
2. Your financial institution account number:
3. Type of Account:
Savings
Checking
4. Password (mandatory security feature) of your choosing: __ __ __ __
Use four numeric digits.
EFT CONTACT PERSON
EFT Contact Person (please print): ____________________________________ DATE:________________
Mailing Address of Contact Person: __________________________________________________________
Telephone Number: ___________________________ Fax Number: _______________________________
E-mail Address: ________________________________
If a tax service will be making your payments, please complete the following information:
Tax Service Name: ______________________________________________________
Tax Service Address: ____________________________________________________
Telephone Number: ___________________________ Fax Number: _______________________________
E-mail Address: ________________________________
Complete this form and send it to:
or fax it to:
or e-mail it to:
EFT Registration
515/281-5830
idrfeft@idrf.state.ia.us
Iowa Department of Revenue
PO Box 10413
You will receive a detailed EFT information
Des Moines IA 50306
booklet describing both options.
92-116 (1/4/05)

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