Form 41 0060-1e (A) - Authorization Instructions & Agreement For Electronic Funds Transfer (Eft) For Excise Tax Payments

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Washington State
AUTHORIZATION INSTRUCTIONS & AGREEMENT
Department of Revenue
(DOR Use Only)
PO Box 47476
FOR ELECTRONIC FUNDS TRANSFER (EFT)
Olympia WA 98504-7476
New
Change
FOR EXCISE TAX PAYMENTS
Bank Location
Important:
No.______________
The information provided on this form does not give the Washington State Department
ELF
of Revenue (DOR) or the Department’s bank authorization to withhold from your
account funds not authorized for payment to the Department.
(Touch Tone)
DOR Tax Reporting Account Number
Reset This Form
Instructions on Back
Business Ownership (Legal Entity)
I
Check here if name change
Firm/Trade Name (DBA)
Mailing Address (Street Address, Box Number, City, State, Zip)
E-mail Address
Fax Number
(
)
Contact Name
Title
Phone
(
)
Contact Name
Title
Phone
(
)
II
Automated Clearing House (ACH) Debit
Select one method:
Touch-Tone
Voice
I will be responsible for contacting the ACH Network, specifying the amount and effective date of my payment. I hereby
authorize DOR’s designated bank to obtain authorized debit entries for such payments to the bank account listed below. My
bank is authorized to debit such account. This authority is to remain in full force until EFT payments are no longer required
or until mutual agreement between DOR and Taxpayer can be reached.
Name on Bank Account
Checking Account Number
Bank Name
Transit & Routing Number
Branch
Please Attach a Copy of Voided Check
III
Automated Clearing House (ACH) Credit
I will be responsible for contacting my bank, indicating the amount I want sent and having the transaction completed
timely for funds to be received by the Department of Revenue on or before the EFT Due Date. DOR is requested to grant
authority for the above named taxpayer to initiate ACH credit transactions to DOR’s bank account. Please see instructions
on reverse side of this form for payment format requirements.
IV
Electronic Refund Information
Electronic refunds may be provided for taxpayers paying electronically. Please indicate below the bank information
necessary to credit the account for refunds. A refund check will be processed if this section is not completed.
Name on Bank Account
Checking Account Number
Bank Name
Transit & Routing Number
Branch
Please Attach a Copy of Voided Check
V
Authorized Representative Signature(s)
Name
Title
Signature
Date
07/18/00
/
/
Name
Title
Signature
Date
07/18/00
/
/
Distribution:
White - Mail to Department of Revenue
Canary - Taxpayer Copy
REV 41 0060-1e (a) (07/26/06)
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