Revision Request For Automated Clearing House (Ach) Debit Account Payments Form - New Jersey Department Of The Treasury
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1State of New Jersey
DEPARTMENT OF THE TREASURY
DIVISION OF REVENUE
PO Box 628
TRENTON, NJ 08646-0628
R. David Rousseau
Jon S. Corzine
State Treasurer
Governor
New Jersey Electronic Funds Transfer (EFT) Program
Re: Revision Request for Automated Clearing House (ACH) Debit Account Payments
Dear Taxpayer:
Please follow the steps below to ensure the proper revision of bank account information and to minimize the possibility of a
failed electronic payment.
Visit https:// , complete the identification fields, and click on the Log On button. Next, click on Maintain
Enrollments to update bank account information online. Account information will be updated immediately.
Or
Complete the information below and fax it to the Division of Revenue at (609) 292-1777, or mail it to: New Jersey Division of
Revenue, EFT Unit, PO Box 191, Trenton, NJ 08646-0191. Allow 15-20 business days from the beginning date (see below) to
process this request.
*PLEASE INDICATE BEGINNING DATE (Required) OF NEW ACCOUNT: ____/_____/_____ (fill in). Do not send EFT payments for the
payment types listed below on/after the date selected above, until notified by the Division of Revenue. In the interim, e-check payments may
be used to make some payments at Continue to use e-checks until advised by the
Division to resume EFT.
Contact the EFT Unit at (609) 984-9830, or email DORInfo@treas.state.nj.us for general questions or to confirm that the e-check option is
available for a particular payment type. Returns should be submitted as usual. Do not send checks and/or returns to the EFT Unit.
*Note: Using EFT after the date indicated (above) and before notification from the Division may cause payments to not be properly debited,
resulting in the assessment of penalty and interest charges.
Taxpayer Name: _______________________________________________________ NJ Reg #: _ _ _ - _ _ - _ _ _ _ / _ _ _
Contact Name: ________________________________________________________ Phone: (
) ________________________
Address: _____________________________________________________________ Fax #: (
) ________________________
City: ________________________________________________ State: ________
Zip: _____________________
Account Type: ____Checking
_____Savings
New Transit/Routing #: __________________ New Bank Acct. # _________________________ Payment Type ____________
New Transit/Routing #: __________________ New Bank Acct. # _________________________ Payment Type ____________
New Transit/Routing #: __________________ New Bank Acct. # _________________________ Payment Type ____________
New Transit/Routing #: __________________ New Bank Acct. # _________________________ Payment Type ____________
New Transit/Routing #: __________________ New Bank Acct. # _________________________ Payment Type ____________
The New Jersey Division of Revenue is hereby authorized to debit entries to the bank account(s) identified above and the bank is authorized
to debit such account(s). The authority is to remain in full force until EFT payments are no longer required by statute or, if I am a voluntary
participant, until the New Jersey Division of Revenue and I mutually agree to terminate my participation in the EFT program.
Signature: ___________________________________
Title: ________________________________
Date: _______________
Please visit the Division of Revenue's web site at
•
New Jersey Is An Equal Opportunity Employer
Printed on Recycled and Recyclable Paper
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(9/06)
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