Form Ri-Eft-1 - Authorization Agreement For Electronic Funds Transfers (2012) Page 2
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1
2CHOOSE ONLY ONE OF THE TWO PAYMENT OPTIONS BELOW
C. ACH DEBIT OPTION
This section is to be completed only if you choose the ACH DEBIT OPTION.
TWO DEBIT OPTIONS AVAILABLE:
1. INTERNET FILING:
Simply log onto https:// and click on the first time user link. This is the only EFT registration
process that you need to do.
Do not complete or remit this form to the RI Division of Taxation EFT Section.
2. TELEPHONE:
Complete Section C and remit authorization agreement to the RI Division of Taxation EFT Section.
If ACH Debit is chosen, you authorize the Rhode Island Division of Taxation to present debit entries to your bank for the tax identified
on the front. Only you can initiate a debit by calling the state's service bureau and indicating the amount of tax to be paid by electronic
funds transfer.
Enclose a copy of a voided check or have an AUTHORIZED REPRESENTATIVE of your bank complete and sign this section of the
form.
BANK NAME:
ADDRESS:
CITY:
STATE:
ZIP CODE:
BANK ACCOUNT #:
BANK ROUTING/TRANSIT NUMBER:
[ ]
CHECKING
[ ]
SAVINGS
Printed Name of Bank Representative
Telephone Number
Signature of Bank Representative
Date
D. ACH CREDIT OPTION
This section is to be completed only if you choose the ACH CREDIT OPTION.
All ACH CREDIT must be initiated in the required CCD+ and TXP format. Any payments not received in that format may
be considered late.
Generic TXP addendum record CCD format
Example:
FIELD #:
FIELD NAME:
DATA ELEMENT TYPE:
FIELD LENGTH:
COMMENTS:
Segment Id
TXP
Field Separator
*
TXP01
Taxpayer Id
AN
11
12345678900
Field Separator
*
TXP02
Tax Type Code
ID
5
55555
Field Separator
*
TXP03
Tax period End Date
DT
6
YYMMDD
Field Separator
*
TXP04
Amount Type
ID
1
T(Tax)
Field Separator
*
TXP05
Amount Paid
N2
1/10
$$$$$$$$cc
Record Terminator
/
This form must be completed and mailed to:
Electronic Funds Transfer Program
Rhode Island Division of Taxation
One Capitol Hill
Providence, RI 02908-5800
Phone: (401) 574-8484
Fax: (401) 574-8913
RI-EFT-1
06152012
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