Electronic Funds Transfer - Change In Bank Information - Rhode Island Division Of Taxation

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STATE OF RHODE ISLAND
DIVISION OF TAXATION
ONE CAPITOL HILL
PROVIDENCE, RI 02908
(401) 574-8484 - phone
(401) 574-8913 - fax
ELECTRONIC FUNDS TRANSFER - CHANGE IN BANK INFORMATION
NAME OF COMPANY: _________________________________________________________________
RHODE ISLAND ID #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
TAX TYPE CODE (S) AFFECTED BY THE CHANGE:
__________________________________________________________________________________________
OLD BANK INFORMATION:
BANK NAME: _________________________________________________________________
BANK TRANSIT/ROUTING NUMBER: ___ ___ ___ ___ ___ ___ ___ ___ ___
(9 DIGITS)
BANK ACCOUNT NUMBER: ____________________________________________________
NEW BANK INFORMATION:
BANK NAME: ________________________________________________________________
BANK TRANSIT/ROUTING NUMBER: ___ ___ ___ ___ ___ ___ ___ ___ ___
(9 DIGITS)
BANK ACCOUNT NUMBER: ___________________________________________________
ACCOUNT TYPE:
CHECKING
SAVINGS
EFFECTIVE DATE OF CHANGE: ____________________________ (This must be at least 7 banking days in
the future from the date that this form is received.)
PERSON COMPLETING THIS FORM _________________________________________________________
TYPE OR PRINT NAME
PHONE NUMBER _________________________________
FOR OFFICE USE ONLY:
Bank Change Completed:
Date:
______________________
Init:
______________________
10
(Revised April 19, 2012)

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