Eft Telepay Worksheet - Oregon Department Of Revenue Page 2
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1
2Department of Revenue Use Only
Date Received
ACH DEBIT AUTHORIZATION AGREEMENT AND APPLICATION
• Please type or print legibly in black ink.
• Check the correct box to indicate whether this is a new application or a change.
• Attach a letter from your bank or a voided check to your completed application.
• Return your completed application to the address listed below.
New
Change
Business Name
Oregon Combined Payroll Business Identification Number
Address
City
State
ZIP Code
Contact Person
Telephone Number
E-mail Address
Fax Number
I (we) hereby authorize the Oregon Department of Revenue to initiate entries to my (our):
Business Checking Account
or
Business Savings Account
and the financial institution named below to debit the same to this account in payment of
Oregon Combined Payroll Tax and Assessments.
Financial Institution
Branch Name or Address
City
State
ZIP Code
Account Number
Bank Routing Number
Business Name (as it appears on the bank account)
This authority is to remain in full force and effect until the above named financial institution
has received written notification from me (or either of us) of its termination so as to afford
the interested parties a reasonable time to act on it.
X
Name (typed or printed)
Signature
Date
X
Name (typed or printed)
Signature
Date
— You must attach a voided check or a letter from your bank to your completed application —
150-206-029-2 (Rev. 6-98)
Send your completed agreement (with attachment) to:
EFT Coordinator
Information Processing Division
Oregon Department of Revenue
PO Box 14725
Salem OR 97307-5018
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