Authorization Agreement Form & Instructions For Electronic Funds Transfer (Eft) For Excise Tax Payments
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1Washington State
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Department of Revenue
Authorization Agreement & Instructions for
PO Box 47476
Olympia WA 98504-7476
Electronic Funds Transfer (EFT) for Excise Tax Payments
Important: Completing this form allows only the funds you have authorized for payment to be withdrawn from your
account by the Washington State Department of Revenue, or the Department’s bank.
UBI/Tax Reporting Number
Instructions on Back
Business Ownership (Legal Entity)
1.
Check here if name change
Firm/Trade Name (DBA)
Mailing Address (Street Address, Box Number, City, State, Zip)
E-mail Address
Fax Number
Contact Name
Title
Phone
Contact Name
Title
Phone
2.
Select one option below by checking the appropriate box
Electronic Funds Transfer (EFT) Debit option (complete banking information below)
I hereby authorize DOR’s bank to make a debit entry for the payment to my bank account listed below. My bank is
authorized to debit my account. This authority remains in full force until canceled.
Name on Bank Account
Checking Account Number
Bank Name
Routing Transit Number
Branch
Please Attach a Copy of Voided Check
Electronic Funds Transfer (EFT) Credit option
I will be responsible for contacting my bank, indicating the amount I want sent and making sure the transaction is
completed timely for funds to be received by the Department of Revenue on or before the EFT Due Date. Please see
instructions on reverse side of this form for payment format requirements.
3.
Complete this section to receive refunds electronically
To receive refunds electronically, please provide the bank information necessary to credit your account and attach a
voided check. A refund check will be processed if this section is not completed or voided check is not attached.
Name on Bank Account
Checking Account Number
Bank Name
Routing Transit Number
Branch
Please Attach a Copy of Voided Check
4.
Authorized Representative Signature(s)
Name
Title
Signature
Date
/
/
Name
Title
Signature
Date
/
/
REV 41 0060e-1 (3/11/10)
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