Form 4515 - Electronic Funds Transfer (Eft) - Account Update

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Michigan Department of Treasury

4515 (Rev. 08-12)

Electronic Funds Transfer (EFT) - Account Update

This form is intended for accounts currently registered for EFT debit filing. Complete the requested information if you choose to add or delete a tax to be paid using EFT.

PART 1: ACCOUNT INFORMATION

Company Name

User ID Code (5 or 6 digits)

Taxpayer Identification Number

Address

E-Mail Address

City

ZIP Code

Contact Person Telephone Number

State

Contact Person

Contact Person Fax Number

PART 2: TAX INFORMATION

Check the appropriate box to add or delete a tax to be remitted by EFT debit (check all that apply).

ADD

DELETE

ADD

DELETE

Flow Through Withholding Corporate Quarterly (02010)

Withholding - Employer and Retirement (01100)

Sales Tax (04200)

Flow Through Withholding Individual Quarterly (02020)

Use Tax on Sales and Rentals (04400)

Flow Through Withholding Annual (02675)

Use Tax on Purchases (04500)

Motor Fuel (05000)

Single Business Tax Annual (02671)

IFTA (05900)

Michigan Business Tax Extension (02355)

Tobacco Products Tax (07300)

Michigan Business Tax Annual (02655)

Tobacco Products Proposed Adjustments (07311)

Corporate Income Tax Annual (02670)

Tobacco License Fee/Equity Assessment (07321)

Corporate Income Tax Estimate (02170)

Tobacco Stamp Fee (07331)

Corporate Income Tax Extensions (02370)

- Provide the date you wish to begin making the EFT debit payments for the tax type(s) checked

above. We will try to complete processing by the date you provide.

PART 3: AUTHORIZATION (FOR EFT DEBIT FILERS ONLY)

If you are interested in making EFT debit payments for the taxes selected above, you must give written permission to access the bank account you

have designated to withdraw your authorized funds. You may do this by providing your signature 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

PART 4: CERTIFICATION

Complete this section if you are not currently registered to pay sales tax, use tax, or withholding tax by EFT, and have checked the box in Section 2 to

begin remitting one or more of these taxes by EFT.

Please be aware of officer, member or partner 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 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.......”

Signature of Corporate Officer, Partner, or Member responsible for reporting and/or paying Michigan taxes

Date

Type or Print

Title

If you have any questions, contact the Michigan Department of Treasury at (517) 636-6925. You may fax this form to (517) 636-4356, or mail to:

Sales, Use and Withholding Taxes

Michigan Department of Treasury

PO Box 30427

Lansing MI 48909