Form Eft-1 St - Authorization Agreement For Electronic Funds Transfer Of Sales And Use Tax

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EFT-1 ST
State of Arkansas
DEPARTMENT OF FINANCE AND ADMINISTRATION
Authorization Agreement for Electronic Funds Transfer of Sales and Use Tax
Arkansas Sales Tax/Business Permit Number: (
)
12 digits
Check one of the following boxes:
Initial Filing of the EFT Agreement Form
Change of Bank or Other Information
Effective date of change
PLEASE PRINT OR TYPE
Name of Business or Organization
C
Primary EFT Contact Person
Phone (
)
O
Address
FAX (
)
N
City, ST, ZIP
T
A
Secondary EFT Contact Person
Phone (
)
A
Address
FAX (
)
C
City, ST, ZIP
T
(S)
Signature of Owner, Partner or Officer
Date
CHOOSE ONLY ONE OF THE TWO PAYMENT OPTIONS BELOW
Complete this section only if you choose the ACH DEBIT OPTION
If ACH Debit is chosen, you authorize the Department of Finance and Administration or it's agent to present debit entries to your bank for the tax specified
above. Only you can initiate a debit by calling the State's Service Bureau and indicating the amount of the tax to be paid by EFT.
A
An AUTHORIZED REPRESENTATIVE of your bank must complete and sign this section of the form.
C
Bank Name
H
Bank Address
City, ST, ZIP
B
Bank Acct. #
Routing/Transfer #
D
Checking
Savings
E
Printed Name of Bank Representative
B
I
Signature of Bank Representative
Date
T
Signature of Owner, Partner or Officer
Date
Complete this section only if you choose the ACH CREDIT OPTION
A
An AUTHORIZED REPRESENTATIVE of your bank must sign this section of the form confirming that you and
C
your bank are capable of initiating ACH Credits in the required CCD+TXP format .
H
Bank Name
Bank Address
C
C
City, ST, ZIP
R
Printed Name of Bank Representative
E
D
Signature of Bank Representative
Date
I
T
Signature of Owner, Partner or Officer
Date
Complete this form and return to:
Sales Tax EFT Unit, P.O Box 3566, Little Rock, AR 72203-3566 - Telephone: (501) 682-7107 - FAX (501) 682-7904

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