Form Eft-1 - Authorization Agreement For Electronic Funds Transfers
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1
2Department of Revenue Services
Connecticut Tax Registration Number
EFT-1
State of Connecticut
PO Box 2937
Authorization Agreement for
Hartford CT 06104-2937
Tax Type
Electronic Funds Transfers
EFT-1 (Rev. 12/11)
See back for instructions. Please print or type. Complete in blue or black ink only.
Enter company name and mailing address.
Part 1: Electronic Funds Transfer (EFT) Contact
All Automated Clearing House (ACH) Credit applicants must complete this section.
Primary EFT Contact Person
Name
Telephone number
(
)
Company name or service provider
Email address
Address (number and street)
City
State
ZIP code
Part 2: Payment Options
ACH Debit (Direct Payment)
To make an ACH Debit payment using the Department of Revenue Services (DRS) Taxpayer Service Center (TSC),
you do not need to submit Form EFT-1 to DRS. Simply access the TSC online at or by telephone at
860-289-4829.
ACH Credit
Payment related information must be sent in the standard National Automated Clearing House Association (NACHA)
CCD + TXP format. Confi rm with your bank representative that you and your bank are able to initiate ACH Credit transactions.
We will mail instructions and formats to the EFT contact person after we receive a completed authorization agreement.
Please provide the following information:
Bank Information
Bank name
Bank address (number and street)
City
State
ZIP code
Taxpayer (owner, partner, or corporate offi cer) signature
Title
Date
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Parent category: Financial