Form Wv/eft-5 - Electronic Funds Transfer Application - West Virginia State Tax Department
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1
2West Virginia State Tax Department
WV/EFT-5
REV. 6/03
Electronic Funds Transfer Application
New
Change Taxpayer
Change Name
Change Bank
Change Bank Transit
Withdrawl
Application
ID Number
or Address
Account No.
or Routing No.
A
TAXPAYER ID
C
C
BUSINESS NAME
O
U
N
ADDRESS
T
C
EFT Contact Person:
O
N
Address:
T
A
C
Telephone: (
)
E-Mail:
T
Consumer Sales
Corporate
Business
Use Tax
Other:
& Direct Pay
Net Income
Franchise
Purchaser/Retailer
(Specify)
T
Personal Income
04201
02095
02091
04502
20099
Annual
A
01080
X
Health Care
Surface Mining
Timber
Telecom-
Provider
Reclamation
Severance
munications
Personal Income
16066
08813
08694
01993
T
Estimated
Y
Business &
Cigarette/
Gasoline
Gasoline
01290
Occupation
Tobacco
Excise
Retail Dealers
P
04603
07208
05160
05250
Personal Income
E
Bill Payments
S
Solid Waste
Soft Drink
Severance
Withholding
01075
12096
07609
08692
01170
Complete Either Debit Section or Credit Section
ACH Debit - Taxpayer calls West Virginia Tax Department Pay-by-Phone System
I hereby authorize the State of West Virignia, hereinafter called STATE, to initiate debit entries and to initiate, if necessary credit entries as adjustments for
any entries in error into my bank account indicated below and the Financial Institution named below, hereinafter called DEPOSITORY, to debit the same
any amount(s) owed by me to the State of West Virignia. This authority is to remain in full force and effect until STATE has received written notification
from me of its termination in such time and in such manner as to afford STATE and DEPOSITORY a reasonable opportunity to act on it.The use of an
EFT PIN will be required to convey my instructions for each transaction. The EFT PIN may be used by me or by my agent.
Bank Account Number
Transit/Routing Number (See Reverse)
Type of Account:
Checking
Bank Account Name
Savings
Authorized Signature
Title
Date
*A voided check for the bank account indicated above MUST accompany this application
ACH Credit - Taxpayer initiates through own bank
I have contacted my bank and confirmed the bank can initiate Automated Clearing House credit transactions that meet West Virginia State Tax
Department requirements. For verification the West Virginia State Tax Department may contact:
Name of Bank
Bank Contact Person
Telephone No.
I hereby request the West Virginia State Tax Department grant authority for the above named taxpayer to initiate Automated Clearing House
transactions to the State of West Virginia's electronic funds transfer account. I understand these must be in the NACHA CCD+ format using the
Tax Payment (TXP) Convention and may only be initiated for the tax types that have been registered for EFT payments with the West Virginia
State Tax Department.
Authorized Signature
Title
Date
Mail completed application to: WV STATE TAX DEPT., RD-EFT, PO BOX 11895, CHARLESTON WV 25339-1895
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