Form Wv/eft-5 - Electronic Funds Transfer Application
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2West Virginia State Tax Department
WV/EFT-5
REV 07/13
Electronic Funds Transfer Application
New
Change Banking
Withdraw
Change Payment
Change Name or
Add Taxes
Information
Application
Type
Address
Participation
ID Number:
A
C
Business Name:
C
O
Address:
U
N
T
C
EFT Contact Person:
O
N
Address:
T
A
C
Telephone:
(
)
E-Mail:
T
Choose Debit OR Credit. To file and pay West Virginia taxes online with ACH Debit, click the MyTaxes link on our website at
ACH Debit -
Taxpayer initiates payments through the West Virginia Tax Department Pay-by-Phone System
I hereby authorize the State of West Virignia, hereinafter called STATE, to initiate debit entries and to ini iate, if necessary credit entries as adjustments for
any entries in error into my bank account indicated below and the Financial Institu ion named below, hereinafter called DEPOSITORY, to debit the same
any amount(s) owed by me to the State of West Virignia. This authority is to remain in full force and effect until STATE has received written notification from
me of its termination in such ime and in such manner as to afford STATE and DEPOSITORY a reasonable opportunity to act on it.The use of an EFT PIN
will be required to convey my instructions for each transaction. The EFT PIN may be used by me or by my agent.
Transit/Routing Number
Type of Account:
Checking
Bank Account Name
Bank Account Number
Savings
Title
Date
Authorized Signature
*A voided check for the bank account indicated above MUST accompany this application
ACH Credit - Taxpayer initiates through own bank
I have contacted my bank and confirmed the bank can initiate Automated Clearing House credit transac ions that meet West Virginia State Tax
Department requirements. For verification the West Virginia State Tax Department may contact:
Name of Bank
Bank Contact Name/Phone
I hereby request the West Virginia State Tax Department grant authority for the above named taxpayer to initiate Automated Clearing House
transac ions to the State of West Virginia's electronic funds transfer account. I understand these must be in the NACHA CCD+ format using the
Tax Payment (TXP) Convention and may only be initiated for the tax types hat have been registered for EFT payments with the West Virginia
State Tax Department.
Date
Au horized Signature
Title
*West Virginia does not accept electronic payments originating outside the United States
PLEASE INDICATE THE TAXES YOU WISH TO INCLUDE ON PAGE 2.
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Parent category: Financial