Form Eft-001 - Taxpayer Registration/authorization Form

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GEORGIA EFT
EFT-001 (Rev . 11/08)
ACH- Debit
Taxpayer Registration/Authorization Form
1.
Taxpayer Name:
_______________________________________________________
2.
Email Address:
_______________________________________________________
3.
Address:
_______________________________________________________
City/State/Zip:
_______________________________________________________
4.
State Taxpayer ID#:
_______________________________________________________
5.
Type of Tax Payment:
_______________________________________________________
6.
1st Contact Person:
________________________________
Title: _____________
Phone:
________________ Ext.:
_________
Fax:
_____________
7.
2nd Contact Person:
________________________________
Title: _____________
Phone:
________________ Ext.:
_________
Fax:
_____________
8.
Type of Electronic Funds Transfer: ACH-DEBIT
Bank: ________________________________________ Day Phone:
___________________
Mailing Address:
____________________________ Night Phone: ___________________
City/State/Zip:
____________________________ Fax:
___________________
Transit/Routing #:
_____________________________________________________________
Bank Account #:
____________________________ [ ] Checking [ ] Savings (check one)
9.
Bank Contact Person: _____________________________ Title: _____________ Phone: ___________
Checking account: Please attach a copy of your voided check.
Savings account: Please attach a copy your deposit slip.
10.
Method of Transmittal (check one):
[ ]
Touch Tone
[ ] Internet
[ ]
Voice Initiated
11.
I/we authorize the Georgia Department of Revenue to present debit entries into the bank account
referenced above. These debits can be made only after I/we notify the Georgia EFT Service Center
to initiate the transfer of funds.
Signature:____________________________________ Title: ____________________ Date: ____________
Signature:____________________________________ Title: ____________________ Date: ____________
Please complete and return by mail or fax to: 404-362-2795
Georgia Department of Revenue-EFT registration
P.O. Box 49512
Atlanta, GA 30359-1512

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