State Of Nebraska Ach Enrollment Form
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1STATE OF NEBRASKA ACH ENROLLMENT FORM
Mail or Fax to:
If you have any questions when completing this form,
please contact the State Treasurer’s Office:
Nebraska Department of Revenue
Attn: Collette Schwindt
State Treasurer
PO Box 94818
a
Attn: Treasury Management
CTX or
Lincoln, NE 68509-4818
Rm. 2005, State Capitol
CCD+
Phone: (402) 471-5685
Lincoln, NE 68509
FAX: (402) 471-5804
CHANGE
NEW
Phone: 402-471-2455
E-mail questions only to: Collette.Schwindt@nebraska.gov
FAX: 402-471-0816
(Please do not e-mail this form)
It is the Financial Institution’s responsibility to assure the accuracy
The information below should be completed by the taxpayer.
The information is used by the State of Nebraska to issue ACH
of the following banking information. If there are any questions,
please contact the State Treasurer’s Office at 402-471-2455.
payments to your bank account. If there are any questions, please
contact Collette Schwindt at (402) 471-5685.
Financial Institution Information
Taxpayer Information
Name:
(as shown on your income tax return)
Name:
Business Name:
(if different from above)
Address:
Remit to Address:
ACH Coordinator:
Federal Tax ID #:
Phone #:
Contact Person:
FAX #:
Phone #:
Nine Digit Routing Transit #:
FAX #:
Depositor Account #:
E-mail:
(e-mail address will be used for notification of ACH payment)
Depositor Account Title:
This authorization may be used for (check one):
CHECKING
SAVINGS
Type of Account:
All payments by the State of Nebraska
Check here if the bank is outside of the United States
All Department of Revenue payments
Check here if the following must be discussed with your entity: There
Department of Revenue - Incentive payments only
are new processing requirements for electronic vendor payments that
are being sent to a financial institution outside of the United States.
If our payments to you are being forwarded from a U.S. financial
Dept. of Revenue - Corporate Income Tax only
institution to a financial institution in another country, please advise
Other (specify)
(identify who within your company).
It is the responsibility of the taxpayer to obtain the ACH payment related remittance information by requesting it from their
financial institution. The State of Nebraska will continue to send the payment related remittance information through the ACH network
in the payment addenda record(s). ACH Rules state the financial institution is required to provide this information to the taxpayer
by the opening of business on the second banking day following the settlement date of the payment. Please contact the ACH
department at your financial institution regarding the services your bank provides to obtain the payment information.
(Please print or type – Authorized Signature Required for verification
(Please print or type – Signature Required)
of bank routing and account numbers)
Authorized Signature:
Authorized Bank Signature:
Name:
Name:
Title:
Title:
Date:
Date:
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