Form Nucs-4050eps - Ach Debit Authorization Request - Electronic Payment System (Eps) For Ui Taxes

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State of Nevada
Department of Employment, Training & Rehabilitation
Employment Security Division
Nevada Unemployment Insurance
500 E. Third Street, Carson City, NV 89713-0030
ACH Debit Authorization Request
Electronic Payment System (EPS) For UI Taxes
New Request
Change Bank Acct/Routing #
Change Threshold Amount
Change Contact Info
INSTRUCTIONS: Please mail this request to the address above, or fax to (775) 684-6351. For verification purposes include a
voided check, or a bank specification sheet from the account to be debited. The department must verify the account number and
routing transit numbers before granting authorization. For security purposes you must also specify a “threshold” amount that
each payment cannot exceed. The threshold amount should be greater than the highest single payment you anticipate making.
Account to be Debited From:
Checking
Or
Savings
Bank Account Number
Routing Number of Banking Institution
For security purposes, taxpayer will not authorize any transfer amount over $________________________________.
Any attempt to transfer funds over this threshold amount will not be accepted.
Nevada Unemployment Insurance Account to be Credited:
Employer Account Number
DBA
FEIN # ________________________
Multiple Accounts?
Yes
No
Agent?
Yes
No
Contact Person ________________________________________ Title_______________________________________
Company Name___________________________________________________________________________________
Mailing Address ___________________________________________________________________________________
Telephone # (________)_________________Ext.________Email Address ____________________________________
Authorization is hereby given to the Nevada Department of Employment, Training & Rehabilitation to initiate ACH debit
entries into the bank account referenced above and credit the Nevada Unemployment Insurance Account named above. These
debits pertain only to Electronic Fund Transfer payments that the taxpayer has initiated for payment to the Employment
Security Division for Unemployment Insurance. I understand that I must request in writing any changes or termination to my
EPS account. All requests must be directed to the address above. Transactions completed on state holidays, weekends, or after
5 p.m. Pacific Time will not be processed until the next regular business day. Debits not honored by the taxpayer’s banking
institution are subject to a $25 fee. Please direct any questions to the EPS Customer Service Desk at (775) 684-6345.
Information is also available at .
Authorized Signature
Title
Date
(Legal signatures include: sole proprietor-owner, corporate officer, and managing member.)
Authorized Signature
Title
Date
(Legal signatures include: sole proprietor-owner, corporate officer, and managing member.)
NUCS-4050EPS (Rev 4/11)

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