Form Sdat Eft-1 - Authorization Agreement For Electronic Funds Transfer - Maryland Department Of Assessments And Taxation
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1State of Maryland
Department of Assessments and Taxation
FORM
Authorization Agreement for Electronic Funds Transfer
SDAT EFT-1
Name of Corporation:
Public Service Company Franchise Tax
Tax Type:
Department I.D. Number:
THIS SECTION MUST BE COMPLETED BY ALL TAXPAYERS
C
Primary EFT contact person__________________________________________________________________________________________
O
N
Address__________________________________________________________________________________________________________
T
A
________________________________________________________________
________________ ____________________________
A
C
City
State
Zip
Telephone Number
T
Secondary EFT contact Person________________________________________________________________________________________________
P
E
Address___________________________________________________________________________________________________________________
R
S
O
______________________________________________________________________________________________________________________
N
City
State
Zip
Telephone Number
(S)
_____________________________________________________________________________________________________________________________
Signature of officer
Title
Date
CHOOSE ONLY ONE OF THE TWO PAYMENT OPTIONS BELOW
This section to be completed only if you choose the ACH DEBIT OPTION
If ACH Debit is chosen you authorize the Department of Assessments and Taxation to present debit entries to your bank for the
tax identified above. Only you can initiate a debit by calling the state’s service bureau and indicating the amount of tax to be
A
paid by electronic funds transfer. An AUTHORIZED REPRESENTATIVE of your bank must complete this section of the form.
C
H
Bank Name _____________________________________________________________________________________
D
E
B
B
Bank Address __________________________________________________________________________________
I
T
________________________________________________________________________________________________________
City
State
Zip
Bank account number______________________________________ Bank routing/transfer number________________________
Printed name of bank representative
Telephone Number
__________________________________________________________________________________________________________
Signature of bank representative (optional)
Date
____________________________________________________________________________________________________________
Signature of Officer
This section to be completed only if you choose the ACH CREDIT OPTION
An AUTHORIZED REPRESENTATIVE of your bank must complete and sign this section confirming that you and your bank are
capable of initiating ACH CREDITS in the required CCD+ TXP format.
A
C
H
Bank Name _____________________________________________________________________________________
C
Bank Address __________________________________________________________________________________
R
C
E
D
I
City
State
Zip
T
Printed name of bank representative (optional)
Telephone Number
_________________________________________________________________________________________________
Signature of bank representative
Date
This form must be completed and mailed to: Dept. of Assessments & Taxation - Franchise Tax Unit
301 W. Preston Street, Baltimore, Maryland 21201-2395
AT3-73
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