Form Ri-Eft-1 - Authorization Agreement For Electronic Funds Transfers (2012)

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State of Rhode Island and Providence Plantations
Department of Revenue
Division of Taxation
One Capitol Hill
Providence, RI 02908-5800
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFERS
FEDERAL IDENTIFICATION NUMBER:
TYPE OF TAX:
[ ] WITHHOLDING
[ ] SALES/USE
[ ] CORPORATION
[ ] INSURANCE PREMIUMS
[ ] GASOLINE/MOTOR FUEL
[ ] TANGIBLE PERSONAL PROPERTY
[ ] BANK DEPOSITS
[ ] PUBLIC SERVICE GROSS EARNINGS
[ ] BANK EXCISE
[ ] CIGARETTE STAMP
[ ] CONSUMER USE TAX
[ ] LITTER-BEVERAGE CONTAINER
[ ] HOTEL TAX
[ ] HEALTHCARE TAX
[ ] LOCAL MEALS & BEV TAX
[ ] ALCOHOLIC BEV IMPORT SERVICE FEE
[ ] UNIFORM OIL RESPONSE & PREV
[ ] WARWICK PARKING TAX
[ ] PASS-THROUGH
[ ] COMPOSITE INCOME TAX
[ ] TOBACCO PRODUCTS
[ ] E-911 $0.26 WIRELESS SURCHARGE
[ ] E-911 $1.00 WIRELESS SURCHARGE
[ ] E-911 $1.00 WIRELINE SURCHARGE
[ ] TEL-COM EDUCATION ACCESS FUND
[ ] OUTPATIENT HEALTHCARE FACILITY SURCHARGE
[ ] HEALTHCARE IMAGING SERVICES SURCHARGE [ ] HARD-TO-DISPOSE MATERIAL TAX
[ ] PREPAID WIRELESS TELECOMMUNICATIONS CHARGE
Sections A & B below must be completed by all taxpayers
A. COMPANY DATA
COMPANY NAME: _________________________________________________________________
D/B/A: ____________________________________________________________________________
ADDRESS:_________________________________________________________________________
CITY: ___________________________________ STATE: __________ ZIP CODE: ______________
TELEPHONE NUMBER: (________)_____________________
FAX NUMBER: (________)_____________________
B. CONTACT PERSON(S):
Primary EFT contact person:
NAME: __________________________________________ TITLE: ___________________________
ADDRESS:_________________________________________________________________________
CITY: ___________________________________ STATE: __________ ZIP CODE: ______________
TELEPHONE NUMBER: (________)_____________________ Extension _______________
FAX NUMBER: (________)_____________________
E-MAIL ADDRESS: ________________________________________________
Secondary EFT contact person:
NAME: __________________________________________ TITLE: ___________________________
TELEPHONE NUMBER: (________)_____________________ Extension _______________
FAX NUMBER: (________)_____________________
E-MAIL ADDRESS: ________________________________________________
RI-EFT-1
06152012

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