Electronic Funds Transfer
EFT-100
Authorization Agreement
10-02
North Carolina Department of Revenue
Office Use
Name
(First 30 Characters) (USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS)
Federal Employer ID Number
Only
Social Security Number
Address
Fill in applicable circle:
City
State
Zip Code (First 5 digits)
Initial registration - mandatory participant
Initial registration - voluntary participant
Change of Information/Bank Change
Name of Contact Person
Phone Number
(Effective Date: ____________ )
Account ID Number
Title
Fax Number
Fill in applicable circle for tax type:
Alcoholic Beverage
Sales & Use
Address
(Semimonthly only)
Corporate Income
Tobacco Products
Insurance Premium
Utilities Franchise
State
Zip Code (First 5 digits)
City
Utility & Liquor
Motor Fuels
Sales & Use Tax
Piped Natural Gas
Withholding
General Instructions
Complete Part 1 to choose the ACH Debit method. Fill in the circle in Part 2 to choose the ACH Credit method and attach
the required justification.
Part 1. ACH Debit
1.
Payment Method
Touchtone
PC
Voice
Fill in applicable circle:
2.
Financial Institution Name
3.
Financial Institution Address
5. Transit or Routing Number
6. Bank Account Number
4.
Account Type
Fill in applicable circle:
Checking
Savings
Part 2.
ACH Credit
(Attach justification.)
Part 3. Authorized Signatures
(ACH Debit filers must complete both certifications. ACH Credit filers must complete the bottom certification.)
I authorize the Department of Revenue to present debit entries for the bank account and the financial institution named above. Debit transactions will be presented only upon my
express authorization and initiation and will pertain only to electronic funds transfer payments that are initiated for payment of North Carolina taxes.
Authorized Signature
Title
Date
I certify that the individual named above as the contact person is authorized to act on behalf of the taxpayer.
Authorized Signature
Title
Date
MAIL TO: Electronic Funds Transfer Section,
North Carolina Department of Revenue, P.O. Box 25000, Raleigh, North Carolina 27640-0001