Enrollment Agreement - Electronic Funds Transfer (Eft) Of Tax Payments - Ach Credits - Philadelphia Department Of Revenue

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DATE:
CITY OF PHILADELPHIA – DEPARTMENT OF REVENUE
Enrollment Agreement
Electronic Funds Transfer (EFT) of Tax Payments
ACH Credits
This enrollment form is being used to establish a point of contact for participants in this program.
Please complete the information listed below and mail to:
Electronic Government Services Unit
City of Philadelphia
Department of Revenue
1401 John F. Kennedy Boulevard – Room 500
Philadelphia, PA 19102-1697
This enrollment agreement can also be faxed to (215) 686-6828. After the enrollment form is
received, you will be sent our ACH payment manual and be given start-up instructions.
Please contact an E-Gov Services representative if you have any questions.
Name
E-mail
Telephone
Toni Curtis-Ford
toni.curtis-ford@phila.gov
(215) 686-6628
Deadra Jenkins
deadra.jenkins@phila.gov
(215) 686-6459
Lorraine Waters
lorraine.waters@phila.gov
(215) 686-6519
Business Name:
Address:
Mailing Address:
Contact Name:
E-Mail:
Contact Telephone #:
Fax #:
Federal EIN:
City Account #:
Tax Type:

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