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Eft Bank Change Form - Electronic Funds Transfer - Change In Bank Information (Ach Debit Filers Only)

STATE OF RHODE ISLAND

DIVISION OF TAXATION

ONE CAPITOL HILL

PROVIDENCE, RI 02908

(401) 222-6282 – phone

(401) 222-6288 – fax

ELECTRONIC FUNDS TRANSFER - CHANGE IN BANK INFORMATION

(ACH DEBIT FILERS ONLY)

NAME OF COMPANY: _________________________________________________________________

RHODE ISLAND ID #: ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

OLD BANK INFORMATION:

BANK NAME: _________________________________________________________________

BANK TRANSIT/ROUTING NUMBER: ___ ___ ___ ___ ___ ___ ___ ___ ___

(9 DIGITS)

BANK ACCOUNT NUMBER: ____________________________________________________

NEW BANK INFORMATION:

BANK NAME: ________________________________________________________________

BANK TRANSIT/ROUTING NUMBER: ___ ___ ___ ___ ___ ___ ___ ___ ___

(9 DIGITS)

BANK ACCOUNT NUMBER: ___________________________________________________

EFFECTIVE DATE OF CHANGE: ____________________________

PERSON COMPLETING THIS FORM _________________________________________________________

TYPE OR PRINT NAME

FOR OFFICE USE ONLY:

Bank Change Completed:

Date: _____________________

Init: ______________________

EFT Bank Change Form

rev. 04/2000

Eft Bank Change Form - Electronic Funds Transfer - Change In Bank Information (Ach Debit Filers Only)