Form Eft-002 - Ach-Credit Taxpayer Registration/authorization
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EFT-002
(Rev. 06/15/15)
GEORGIA EFT
ACH-CREDIT
Taxpayer Registration/Authorization Form
rd
1. Taxpayer Name:_______________________________ Client ID(If 3
party vendor) ______________
2. Address: ________________________________________________________________________
City: _________________________________________________ State: _____ ZIP: ___________
3. Tax Account Number (Required): _________________________ FEIN ____________________
4. Type of Tax Payment (Check one per Request):
[
] WH [
] Non-Res WH [
] ST [
] Corp [
] 911 Wireless [
] Fireworks Excise [
] State Hotel-Motel
Fee
5. Taxpayer’s Contact Person: _________________________________ Title: _____________________
Phone: ________________ Ext: ______________ Fax: ________________
e-Mail(required):_____________________________________________________________
rd
6. 3
Party Contact For GA Returns & Payments: ___________________________________________
Phone: ________________ Ext: ______________ Fax: ________________
e-Mail(required): _______________________________________________________________
7. I/We declare, under penalties of perjury that I/we have examined this application and to the best of
my/our knowledge and belief it is true, correct, and complete. If prepared by a person other than
taxpayer, his/her declaration is based on all information of which he/she has any knowledge.
Signature _____________________ Title: ________________________ Date: ________________
(Taxpayer)
Signature _____________________ Title: ________________________ Date: ________________
rd
(3
Party Vendor)
Please scan and return by e-Mail to
DOR.ElectronicFundsTransfer@dor.ga.gov
Georgia Department of Revenue
Taxpayer Services Division
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