Authorization For Electronic Deposit Of Vendor Payment Page 2
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24. Complete Section C with the deposit information for the omitted tangible property tax distribution.
Check here and do not complete Section C if account information is the same as Section A.
Check here and do not complete Section C if account information is the same as Section B.
SECTION C
Financial Institution Information
Bank Name: __________________________________________________________________________
Branch: ______________________________________________________________________________
or correspondent bank (if applicable)
City: _____________________________ State: ____________________ Zip: __________________
Transit/ABA No. ______________________________
Account Number: _____________________________________________________________
Account Type (select one):
Checking Account
Savings Account
I, the undersigned, authorize the Commonwealth of Kentucky to initiate accounting transactions to deposit
payments directly to the account indicated above and to correct any errors which may occur from the
nancial Institution to post these transactions to that account.
This
transactions. I also authorize the Fi
authorization is to remain in force until the Commonwealth of Kentucky receives written notice or cancellation
from me.
Signature: __________________________________________ Date: _____________________________
Name Printed: ______________________________________ Job Title: __________________________
Phone #: _________________________ Email: ______________________________________________
Address:
Division of Sales and Use Tax
Station 67
P O Box 181
Frankfort, KY 40602-0181
Phone: 502-564-5170
Fax: 502-564-2041
Email: dor.web.response.telecom@ky.gov
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