Form Eft-1 - Authorization Agreement For Electronic Funds Transfer

Illinois Department of Revenue

EFT-1

Authorization Agreement for Electronic Funds Transfer

Part 1: Complete the taxpayer information

3 ___ ___ - ___ ___ ___ ___ ___ ___ ___

_________________________________________________

Taxpayer’s name

Federal employer identification number (FEIN)

4 ___ ___ ___ ___ - ___ ___ ___ ___

_________________________________________________

Street address

Illinois business tax (IBT) number

5 ___ ___ ___ - ___ ___ - ___ ___ ___ ___

_________________________________________________

P.O. Box, Suite number

Social Security number

If you are the designated agent and completing this authorization form on

_________________________________________________

behalf of this taxpayer, the taxpayer must sign in Part 6, unless you have a

City

State

ZIP

signed Form IL-2848-E in your records for that taxpayer.

Part 2: Complete the designated agent information

(Complete only if the designated agent will be making your payments.)

_________________________________________________

Contact person’s name

Designated agent’s name

_________________________________________________

(_____)_________________

Street address

Telephone number

Fax number

_________________________________________________

If you choose the ACH debit option and the bank account used to make

payments is the designated agent’s, an authorized officer of the agent must

P.O. Box, Suite number

sign below in order to give the department authorization to debit that account.

_________________________________________________

City

State

ZIP

_________________________________________________

Signature authorization for EFT Program (Authorized officer of designated agent)

Part 3: Complete the EFT account registration activity

Initial set up

Changes*

ACH option:

Debit

Credit

(Include effective date.)

(Select only one.)

______________________________________

*Specify change

If you chose the ACH debit option, you must complete Part 5 below.

Part 4: Check all tax payments and fees that apply to this authorization agreement

Corporate Income Tax

IL-1120-ES

IL-505-B

ICT-1

ICT-4

Electricity Dist. and Invested Capital

Withholding Income Tax

IL-501

IL-941

Gas Revenue Tax

RPU-50

RG-1

Individual Income Tax

IL-1040-ES

IL-505-I

Electricity Excise Tax

RPU-50

RPU-13

Sales and Use Tax

RR-3

ST-1

Telecomm. Taxes (state and local)

RPU-50

RT-2

Automobile Renting Occupation and Use Tax

ART-1

Telecomm. Infrastructure Maintenance Fees

RT-10

Chicago home rule municipal

Tobacco Products Tax

TP-1

soft drink retailers’ occupation tax

ST-14

Cigarette Tax (ACH debit option only)

RC-1-A

County Motor Fuel Tax

CMFT-1

Hotel Operators’ Occupation Tax

RHM-1

MPEA Food & Beverage Tax

ST-4

Liquor Revenue Tax

RL-26

Prepaid Sales Tax

PST-3

PST-1

Liquor Revenue Airline Tax

RL-26-A

Part 5: Complete only if the ACH debit payment option is being used

(Consult your financial institution.)

Corporate

Individual/Consumer

_________________________________________________

Account types:

Financial institution’s name

Checking

Savings

_________________________________________________

Street address

Name on account

_________________________________________________

P.O. Box, Suite number

Account number

6 ___ ___ ___ ___ ___ ___ ___ ___ ___

_________________________________________________

City

State

ZIP

Routing transit number

If you pay different tax liabilities using different accounts, you must complete a separate Form EFT-1 for each account. The taxpayer being registered

must sign each Form EFT-1, unless you have a signed Form IL-2848-E in your records for that taxpayer.

Part 6: Signature authorization of taxpayer, authorized officer, or partner

Under penalties of perjury, I state that I have examined this form and to the best of my knowledge it is true, correct, and complete. The Illinois Department of

Revenue is authorized to use this information in accordance with the Department of Revenue Law of the Civil Administrative Code of Illinois and all applicable

Illinois tax acts. This agreement shall remain in force until the department receives written notification from the taxpayer.

_________________________________________________

_______________________

__ __/__ __/__ __ __ __

Signature of taxpayer, authorized officer, or partner

Title

Month Day

Year

(_____)_________________

The EFT contact person’s information must be completed.

Contact person’s telephone number

Fax number