Form Dr 5785 - Authorization For Electronic Funds Transfer (Eft) For Tax Payments

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*145785==19999*
DR 5785 (06/25/14)
COLORADO DEPARTMENT OF REVENUE
Denver CO 80261-0009
(303) 205-8333
EFT Number
Authorization For Electronic Funds
Transfer (EFT) For Tax Payments
To be assigned by Department of Revenue
Taxpayer Name
Contact Person
Set Up New Account
Mailing Address (Street Number, Apt. Number, Box Number)
FEIN or Social Security Number
Modify Account
Telephone Number
Add Taxes
(
)
City, State, ZIP
Fax Number
Remove Taxes
(
)
Add Additional EFT Number(s)
Email Address
Tax To Be Paid by EFT Transactions.
Must be completed for either ACH debit or ACH credit.
See listing of taxes and tax type codes on reverse side.
Tax Type
Tax Type Code
Your DOR Account
Complete Section 1 and/or 2
Section 1—ACH Debit
ACH Debit—taxpayer selects the EFT payment option on our web page or calls a toll free number
I hereby authorize the Colorado Department of Revenue (DOR), to initiate debit entries to my banking account.
This authority is to remain in full force and effect until DOR and Financial Institution have received written
notification from me of its termination in such time and in such manner as to afford DOR and FI a reasonable time
to act on it. The use of an EFT identification number and password will be required to convey my instructions for
each transaction. The EFT identification number and password may be used by me or by my agent. You will be
able to provide your banking information 24 hours after your registration for EFT.
(MM/DD/YY)
Authorized Signature
Title
Date
Section 2—ACH Credit
ACH Credit—taxpayer initiates through own financial institution.
I have contacted my financial institution and confirmed the financial institution can initiate Automated Clearing
House credit transactions that meet Colorado Department of Revenue (DOR) requirements. For verification, DOR
may contact:
Name of Bank
Bank Contact Person
Telephone Number
I hereby request DOR grant authority for the above named taxpayer to initiate Automated Clearing House credit
transactions to DOR's bank account. I understand these must be in the NACHA CCD+ format using the Tax Payment
(TXP) Convention and may only be initiated for the tax types that have been registered for EFT payments with DOR.
(MM/DD/YY)
Authorized Signature
Title
Date
Please return application to: Colorado Department of Revenue, Denver CO 80261-0009
or fax to (303) 866-3112.

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