Form Eft-100 - Electronic Funds Transfer Authorization Agreement - 2002

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