Electronic Funds Transfer Authorization Agreement (Page 2 of 2) in pdf

Electronic Funds Transfer Authorization Agreement Page 2

VIRGINIA DEPARTMENT OF TAXATION

ELECTRONIC FUNDS TRANSFER AUTHORIZATION AGREEMENT

(Page 2)

IF CHOOSING THE ACH CREDIT PAYMENT METHOD, COMPLETE THIS SECTION

For each tax type to be paid by EFT, enter the Virginia Tax Account Number(s) and FEIN.

Corporation Income Tax

_________________________ FEIN__________________________

Va Tax Account Number

Federal Employer ID Number

Employer Withholding Tax ______________________ FEIN_______________________

Va Tax Account Number

Federal Employer ID Number

Sales & Use Tax

_______________________ FEIN_______________________

Va Tax Account Number

Federal Employer ID Number

Communications Tax

_______________________ FEIN_______________________

Va Tax Account Number

Federal Employer ID Number

ALL TAXPAYERS COMPLETE THIS SECTION

By signing this form, I agree that I am responsible for accounting for and paying over the required

taxes and that I will notify the Department of Taxation in the event that I am no longer responsible

for accounting for and paying over the required taxes. My signature certifies that I understand the

Electronic Funds transfer process; that I agree to file the tax payments designated above using

EFT as outlined in the Virginia EFT Guide and that I will continue to make my tax payments to the

Commonwealth of Virginia as described in Title 58.1 of the Code of VA.

Print Name of Business Owner/Partner/Officer

E Signature of Business Owner/Partner/Officer

Date

FAX this form (and a voided check if you are an ACH Debit filer) to (804) 367-2603 OR make a copy

of the form for your records and mail the original document(s) to:

Virginia Department of Taxation

EFT Program

Questions? Phone (804) 367-8037

P.O. Box 1114

Richmond, VA 23218-1114

Electronic Funds Transfer Authorization Agreement Page 2