Electronic Funds Transfer Authorization - Idaho State Tax Commission
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1Sta
Sta
State of Idaho
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te of Idaho
te of Idaho
te of Idaho
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Of
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Off f f f f ice of the Sta
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ice of the State te te te te T T T T T r r r r r easur
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easurer er er er er
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Of
Of
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Electr
Electr
Electronic Funds
onic Funds
onic Funds
onic Funds T T T T T ransfer
ransfer
ransfer A A A A A uthor
ransfer
uthor
uthoriza
uthor
iza
iza
ization
tion
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Electr
Electr
onic Funds
ransfer
uthor
iza
tion
Taxpayer name
Taxpayer identification number
Contact person
Telephone number
Address
Indica
Indica
Indica
Indica
Indicate which method y
te which method y
te which method y
te which method y
te which method you will be using to f
ou will be using to f
ou will be using to f
ou will be using to f
ou will be using to file electr
ile electr
ile electr
ile electronically
ile electr
onically
onically
onically
onically. . . . .
Automated Clearing House (ACH) Debit
Automated Clearing House (ACH) Credit
T T T T T ax
ax
ax
axes to be paid using EFT
ax
es to be paid using EFT
es to be paid using EFT
es to be paid using EFT
es to be paid using EFT
Idaho ID number
Contact name, address and phone
Tax Type code
A A A A A CH DEBIT ONL
CH DEBIT ONL
CH DEBIT ONL
CH DEBIT ONL
CH DEBIT ONLY Y Y Y Y
If you are using the ACH Debit System, please include a photocopy of one of your checks with “VOID” printed on it in order to
If you are using the ACH Debit System, please include a photocopy of one of your checks with “VOID” printed on it in order to
If you are using the ACH Debit System, please include a photocopy of one of your checks with “VOID” printed on it in order to
If you are using the ACH Debit System, please include a photocopy of one of your checks with “VOID” printed on it in order to
If you are using the ACH Debit System, please include a photocopy of one of your checks with “VOID” printed on it in order to
verify American Bank Association Number and the Bank Account Number.
verify American Bank Association Number and the Bank Account Number.
verify American Bank Association Number and the Bank Account Number.
verify American Bank Association Number and the Bank Account Number.
verify American Bank Association Number and the Bank Account Number.
I/we hereby authorize the Idaho State Treasurer to present debit entries into the bank account referenced above and the depository
named above. These debits will pertain only to Electronic Funds Transfer Payments that the taxpayer has initiated for payment of
Idaho taxes.
Title
Date
Authorized signature
Authorized signature
Title
Date
Bank Account Number
American Banking Association Number
Retur
Retur
Retur
Retur
Return a cop
n a cop
n a cop
n a cop
n a copy of this f
y of this f
y of this f
y of this for or or or orm to:
y of this f
m to:
m to:
m to:
m to:
ID ID ID ID IDAHO ST
AHO ST
AHO ST
AHO STA A A A A TE TE TE TE TE T T T T T AX COMMISSION
AX COMMISSION
AX COMMISSION
AX COMMISSION
AHO ST
AX COMMISSION
Attention:
Attention:
Accounting
Accounting
Attention:
Attention:
Attention: Accounting
Accounting
Accounting
P O Bo
P O Bo
P O Bo
P O Bo
P O Box 36
x 36
x 36
x 36
x 36
Boise,
Boise,
Boise,
Boise,
Boise, Idaho 83722-0120
Idaho 83722-0120
Idaho 83722-0120
Idaho 83722-0120
Idaho 83722-0120
F F F F F AX number: (208) 334-7625
AX number: (208) 334-7625
AX number: (208) 334-7625
AX number: (208) 334-7625
AX number: (208) 334-7625
S S 0 0 5 0 1
8-16-95
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