Form Mf-Eft-1m - Motor Fuel Tax Authorization Agreement For Electronic Funds Transfer
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1
2STATE OF ARKANSAS
STATE OF ARKANSAS
MF-EFT-1
MF-EFT-1
DEPARTMENT OF FINANCE & ADMINISTRATION
DEPARTMENT OF FINANCE & ADMINISTRATION
MOTOR FUEL TAX
MOTOR FUEL TAX
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER
PLEASE ENTER YOUR MOTOR FUEL TAX ACCOUNT NUMBER
GASOLINE IMPORTER #
DIESEL IMPORTER #
GASOLINE 1ST RECEIVER #
DIESEL 1ST RECEIVER #
LP GAS #
PE FEE #
PLEASE PRINT OR TYPE
A
BUSINESS NAME
FEIN
C
PHONE (
)
PRIMARY EFT CONTACT PERSON
O
N
ADDRESS
T
CITY, STATE, ZIP
A
PHONE (
)
SECONDARY EFT CONTACT PERSON
C
ADDRESS
T
(S)
CITY,STATE ,ZIP
SIGNATURE OF OWNER, PARTNER OR OFFICER
DATE
CHOOSE ONLY ONE OF THE TWO PAYMENT OPTIONS BELOW
COMPLETE THIS SECTION ONLY IF YOU CHOOSE THE ACH DEBIT OPTION
B
IF THE ACH DEBIT IS CHOSEN, YOU AUTHORIZE THE DEPARTMENT OF FINANCE & ADMINISTRATION OR ITS AGENT TO PRESENT DEBIT ENTRIES TO YOUR
BANK FOR THE TAX SPECIFIED ABOVE . ONLY YOU CAN INITIATE A DEBIT BY CALLING THE STATE'S SERVICE BUREAU AND INDICATING THE AMOUNT OF
A
TAX TO BE PAID BY EFT.
AN AUTHORIZED REPRESENTATIVE OF YOUR BANK MUST COMPLETE AND SIGN THIS SECTION OF THE FORM.
C
H
BANK NAME
BANK ADDRESS
D
CITY,STATE,ZIP
E
B
ROUTING / TRANSFER #
BANK ACCT.#
I
PRINTED NAME OF BANK REPRESENTATIVE
T
SIGNATURE OF BANK REPRESENTATIVE
DATE
SIGNATURE OF OWNER, PARTNER OR OFFICER
DATE
c
COMPLETE THIS SECTION ONLY IF YOU CHOOSE THE ACH CREDIT OPTION
A
AN AUTHORIZED REPRESENTATIVE OF YOUR BANK MUST SIGN THIS SECTION OF THE FORM
C
CONFIRMING THAT YOU AND YOUR BANK ARE CAPABLE OF INITIATING ACH CREDITS IN
H
THE REQUIRED CCD + TXP FORMAT.
BANK NAME
C
R
BANK ADDRESS
E
CITY, STATE ZIP
D
PRINTED NAME OF BANK REPRESENTATIVE
I
SIGNATURE OF BANK REPRESENTATIVE
DATE
T
SIGNATURE OF OWNER, PARTNER OR OFFICER
DATE
COMPLETE THIS FORM AND RETURN TO :
MOTOR FUEL TAX SECTION, P O BOX 1752, LITTLE ROCK AR 72203-1752
PHONE (501) 682-4800
FAX (501) 682-5599
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