Electronic Funds Transfer (Eft) Authorization - Minnesota Department Of Revenue
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1MINNESOTA Department of Revenue
Electronic Funds Transfer tax types
(FIll in code at right)
Electronic Funds Transfer (EFT) Authorization
002 Sales
005 Non Resident
Taxpayer name
004 Withholding
Entertainer
006 Ind Estimate
044 Mortgage Regis
010 Corp Ann Filing
045 Deed Tax
Mailing address (street, apartment, route)
069 Dry Clean Solvent
011 Corp Estimate
070 Dry Clean Facility
111 Corp Extension
012 Fid Ann Filing
076 Insurance
112 Fid Extension
Premium
Mailing address (city, state, zip)
Telephone number
212 Fid Estimate
078 Firefighter Relief
046 Partnership Ann
Surcharge
Filing
501 Auto Theft
Taxes to be paid using EFT
(see listing of tax type codes at right)
146 Partnership Extension
Surcharge
246 Partnership Estimate
333 Hospital
Tax Type code
Minnesota ID number
Contact name, address and phone
047 S Corp Ann Filing
334 Surgical Center
147 S Corp Extension
335 Wholesale Drug
247 S Corp Estimate
336 Prescription Drug
066 Petroleum
399 Provider
068 Nonprofit Org
Franchise
016 Intox Liquor
030 Malt Beverage
064 Cigarette
ACH Debit – taxpayer initiates through the Department of Revenue
075 Hazardous Waste
I authorize the Minnesota Department of Revenue (DOR) to initiate debit entries to the above named taxpayer’s account(s). This
083 Solid Waste
authority will remain in effect until the DOR has received written notification of its termination at least 30 days prior to the
087 Tobacco
effective date. (You must complete Bank Information, below. You must also fax a copy of a cancelled or voided check to verify
088 Pull Tabs
account and routing and transit number.)
Check here if this is a bank account change.
093 Charitable Gambling
ACH Debit Bank Information:
Bank name:
Phone number
Bank account number (not to exceed 17 digits)
Type of account:
savings
checking
Remember to fax
a copy of your
cancelled or
Routing and transit number (requires 9 digits)
voided
check!
Authorized signature
Date
ACH Credit – taxpayer initiates through own bank
I hereby request the Minnesota Department of Revenue (DOR) to grant authority for the above named taxpayer to initiate
Automated Clearing House credit transactions to the DOR’s bank account. I understand these must be in the NACHA CCD+ format
using the TXP convention and may only be initiated for the tax types listed above.Failure by the taxpayer to include a suitable TXP
convention with the payment will result in a delay to proper posting of the credit.
Authorized signature
Date
Bank account number
Fax this form and a copy of a cancelled or voided check to:
Routing and transit number
Minnesota Department of Revenue Electronic Funds Transfer Unit, 612-296-6604
11/97
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