Form Eft-100d - Ach Debit Payment Method Authorization Agreement

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4
ACH Debit Payment Method Authorization Agreement
EFT-100D
Web-Fill
PRINT
CLEAR
North Carolina Department of Revenue
11-16
Business Name
(First 30 Characters) (USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS)
Federal Employer ID Number
Address
Office Use Only
City
State
Zip Code (First 5 digits)
Name of Contact Person
Contact Phone Number
Social Security Number
Title of Contact Person
Contact Fax Number
Contact Business Name (If different than above)
Fill in applicable circle:
Initial registration - mandatory participant
Address (If different than above)
Initial registration - voluntary participant
Change of Information
City
State
Zip Code (First 5 digits)
(Effective Date: __________________ )
Part 1. Select ACH Debit payment method and tax type (Fill in applicable circle)
Tax type available for these methods:
(Select tax type by filling in applicable circle):
Enter your Account ID for the tax type selected
Insurance
Touchtone
Voice
0 0
Premium
Batch (must only be used to transmit 10 or more payments at a time). Note average number of payments to be transmitted
per transmission ______________________ .
Tax types available for this method:
(Select tax type by filling in applicable circle):
Combined General Rate Sales and Use
(Utility, Liquor, Gas, and Other)
Enter your Account ID/NCDOR ID for the tax type selected
Machinery and Equipment
Tobacco Products
Withholding
0 0
Sales and Use
Alcoholic Beverage
(Federal Employer ID is required):
Enter your Motor Fuels Account ID/NCDOR ID
Corporate Estimated
Insurance Premium
Motor Fuels
Part 2. Enter Banking Information
1.
Financial Institution Name
2.
Account type
Checking
Savings
(Fill in applicable circle):
3.
Transit or Routing Number
4.
Bank Account Number
Part 3. Authorized Signatures
I authorize the North Carolina Department of Revenue to present debit entries for the
I certify that the individual named above as the Contact Person (if not employed by
bank account and the financial institution named above. Debit transactions will be
my business) is authorized to act on my behalf in regards to ACH Debit transactions
presented only upon my express authorization and initiation and will pertain only to
for the tax type indicated.
ACH payments that are initiated for the payment of North Carolina taxes.
Authorized Signature
Taxpayer Signature
Title
Date
Title
Date
MAIL TO: Electronic Payments Unit, North Carolina Department of Revenue, P.O. Box 25000, Raleigh, North Carolina 27640-0001 or FAX TO: 919-733-3149

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Parent category: Business
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