Form Eft - Authorization Agreement For Electronic Funds Transfers Page 2
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1
2
3Instructions for Form EFT
Tax Type: Businesses may use electronic funds transfers
Section C – Complete this section only if you are choosing
(EFT) to file and pay Maryland withholding, motor fuel, and
the ACH Credit option.
corporate income taxes. Accepted corporate forms are 500,
Name and address of the bank: Provide the name and
500D and 500E only. Forms 510, 510D, 510E for Pass-
address of the bank you will be using for electronic funds
Through Entities are NOT accepted.
transfers.
Section A – This section must be completed by ALL
Printed name and signature of bank representative
taxpayers.
(include bank representative’s telephone number): You cannot
•
Business name - required.
use the ACH Credit option unless your bank can initiate
transactions in this format.
•
Maryland Central Registration Number - if registered.
Mail this completed form to:
•
Federal Employer Identification Number - required.
Electronic Funds Transfer Program
•
Motor Fuel Tax Account Number - if applicable.
P.O. Box 1509
•
EFT contact person: The primary contact person
Annapolis, MD 21404-1509
should be someone within your company who will be
directly involved in all phases of the EFT registration
process, system implementation, and the payment of
the tax. Instructions will be mailed to the contact person
designated on the agreement. You also should designate a
secondary contact person.
•
Address: Indicate the mailing address to be used for
correspondence regarding electronic funds transfer.
•
Telephone number: Indicate the telephone number(s)
for the EFT contact person.
•
Signature of owner, partner, or officer: Authorized
signature of owner, partner, or officer of the company.
Section B – Complete this section only if you are choosing
the ACH Debit option.
•
Bank name: Name of the bank you will be using for
electronic funds transfers.
•
Bank address: Indicate the address of the bank branch
you will be using.
•
Bank account number: The account number from which
the state will draw debit entries.
•
Type of account: Check the appropriate box for the type
of account (savings or checking) you will be using for
electronic funds transfer.
•
Bank routing transit number: Your bank’s nine-digit
routing/transit number is required.
•
Signature of owner, partner, or officer: Authorized
signature of owner, partner or officer of the company. This
signature will authorize the Comptroller of Maryland to
present debit entries.
Electronic Funds Transfer Program telephone number 410-260-7980 • Fax: 410-260-6214
Hearing impaired users call via Maryland Relay at 711 in Maryland
2
COM/RAD-072
13-49
Rev. 06/13
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