Form 4536 - International Fuel Tax Agreement Electronic Funds Transfer Debit Application

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Michigan Department of Treasury
4536 (Rev. 06-12)
International Fuel Tax Agreement Electronic Funds Transfer Debit Application
Issued under P.A. 122 of 1991, as amended. Filing is mandatory if you wish to pay by EFT Debit.
Use this form to notify Treasury that you intend to pay your IFTA taxes by EFT Debit. You may begin electronic payment after you receive our approval
and receive instructions for transmitting.
Taxpayer Idenification Number
Taxpayer Name and Address
Contact Person Telephone Number
Contact Person
Contact Person Fax Number
Tax Type: IFTA
Tax Code: 05900
AUTHORIZATION FOR EFT DEBITS
If you are interested in making IFTA Tax payments using the Electronic Funds Transfer (EFT) debit method, you must give written permission to access
your bank account to withdraw the funds you authorize. Please do this by signing below.
I authorize the State of Michigan and its authorized contractor to make variable withdrawals by electronic transfer from the designated financial
institution and account. I understand that only the withdrawals I authorize will be made and that this process is protected by a password and a user
code. I understand that I may cancel this authorization at any time by sending a written notice to the address noted below. I agree to comply with the
National Automated Clearing House Association Rules and Regulations about electronic transfers as they exist on the date of my signature on this
form or as subsequently adopted, amended, or repealed. Michigan law governs electronic funds transactions authorized by this agreement in all
respects except as otherwise superseded by federal law. If multiple signers are required to authorize a withdrawal of funds, all must sign this form.
Signature of Responsible Officer
Title
Date
Additional Signatures (if needed)
Please be aware of corporate officer liability as provided in Michigan Compiled Laws 205.27a(5):
“If a corporation, limited liability company, limited liability partnership, partnership or limited partnership liable for taxes administered under this
act fails for any reason to file the required returns or to pay the tax due, any of its officers, members, managers, or partners who the department
determines, based on either an audit or an investigation, have control or supervision of, or responsibility for, making the returns or payments is
personally liable for the failure.”
CORPORATE OFFICER CERTIFICATION
This form will not be processed for corporations unless this section is completed.
Signature of Officer Responsible for Reporting and/or Paying Michigan Taxes
Date
Type or Print Name
Title
This corporate officer certification must be resubmitted when there is a change in the officer responsible for filing and/or paying Michigan taxes. Mail
this form to the Michigan Department of Treasury for approval. We will sign it and return it to you. You will receive instructions from our contractor for
filing electronic payments.
SECURITY
The security question is required to complete the processing of your application. Please retain a copy of your answer. A correct response is required
when contacting Treasury’s authorized contractor or completing certain updates to your account. You may change the security question and/or
response after successfully accessing your account.
What school did you attend for sixth grade?
If you have any questions, contact the Michigan Department of Treasury at (517) 636-4580.
Return this from to:
Michigan Department of Treasury
PO Box 30474
Lansing MI 48909-8209
Fax: (517) 636-4593
TREASURY USE ONLY
Treasury Appoval
Date

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