Appendix D - Authorization Agreement For Electronic Funds Transfer (Eft) - Ach Credit - Oklahoma Tax Commission

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Oklahoma Tax Commission
Electronic Funds Transfer
APPENDIX D
OKLAHOMA TAX COMMISSION
AUTHORIZATION AGREEMENT
FOR ELECTRONIC FUNDS TRANSFER (EFT) - ACH CREDIT
Method of Tax Report Filing:
(Please check one)
Internet*___________
IVR*______________
Mail-In_______
*not available for all tax types
Complete section concerning the contact person this agency may call.
Indicate which tax(es) will
be payed by EFT and note the Tax Account Number for each tax to be paid.
Filing will only be by
ACH Credit and the CCD+ format.
COMPANY INFORMATION
Company/Organization:
Tax Acct/Permit Number
Tax Type Code
Address:
Contact Person’s Name:
Telephone No. (including Area Code):
E-mail Address:
FEI Number:
Signature and Title of Authorized Official: _________________________________
Date:____________________
***************************************************************************************
FINANCIAL INSTITUTION INFORMATION
Name of Financial Institution:
Telephone Number of Financial
Bank One
Institution:
800-213-8697
9-Digit Routing Transit Number:
Depositor Account Number: 010229187
103000648
(Checking Acct)
Depositor Account Title: State of Oklahoma, Robert Butkin, State Treasurer
******************************************************************************
I hereby authorize the Oklahoma Tax Commission to use the above information in direct conjunction with the
Electronic Funds Transfer Program.
This authority is to remain in full force and effect until the Oklahoma
Tax Commission has received a written termination notification from an authorized officer.
I will comply
with the Electronic Funds Transfer provisions set forth by the Oklahoma Tax Commission.
Signature of Authorizing Official:_______________________________________________________
**************************************************************************************
EFT
Revision Date: August 30, 2002
Page 21

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