Form D-128 - Registration Application For Electronic Funds Transfer
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1
2STATE OF SOUTH CAROLINA
DEPARTMENT OF REVENUE
1350
D-128
REGISTRATION APPLICATION
FOR ELECTRONIC FUNDS TRANSFER
(Rev. 9/16/13)
1086
For Department
(Business Name and Mailing Address)
Use Only
Add
Effective Date:
Change
Employee Verification:
Delete
*Tax Type:
*SC ID (File #):
NOTE: This form is not required to make payments
*FEIN:
on ePay at
*Required
MANDATORY (See instruction sheet attached)
VOLUNTARY PARTICIPANT (Check this block if you want to participate in EFT on a voluntary basis.)
EXEMPT (IDT - Government Agencies)
Please give the name, telephone number and address (if different from above) of company contact person:
Contact Person
(
)
Telephone
Contact Address
(
)
FAX Number
City
State
Zip Code
Two (2) payment options available for Electronic Funds Transfer are: ACH Debit or ACH Credit. You must indicate the option
you select by checking the appropriate box below. SCDOR does not currently support International ACH transactions (IAT).
ACH Debit
ACH Credit
Checking
OR
Savings
For ACH Debit, a copy of a voided check or micro
specification sheet MUST be attached for verification.
Change of bank information on active EFT-ACH Debit set up.
Effective date of change:
Bank Name:
Transit Routing #:
Bank Account Number:
If the ACH Debit option is chosen the taxpayer hereby authorizes the South Carolina Department of Revenue to present
debit entries into the bank account referenced above as required by South Carolina Law. These debits will pertain only to
Electronic Funds Transfer payments that the taxpayer has authorized through the debit procedures.
Signature
Title
Date
The remaining option is cash. This will satisfy the requirement to pay in immediately available funds.
If cash is chosen, please be advised you must hand deliver this payment by 5 p.m. on the due date to the
cashier's office at 300A Outlet Pointe Blvd., Columbia, SC 29214.
Cash
Please return this form to: South Carolina Department of Revenue, EFT/EDI Help Desk, Columbia, SC 29214-0016. If
you have questions, call 1-800-476-0311 or, in the Columbia area, 896-1715 (FAX Number (803) 896-1779).
10861029
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Parent category: Financial