Form 150-102-042 - Ach Credit Electronic Funds Transfer Program Guide Page 10

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Department of Revenue Use Only
Date Received
ACH CREDIT AGREEMENT AND APPLICATION
FOR ESTIMATED CORPORATION EXCISE AND INCOME TAX
Excise
Income
• Please type or print clearly in black ink.
• Check the correct box (above) to indicate whether you are subject to excise or income tax.
• Check the correct box to indicate whether this is a new application or a change.
• Return your completed application to the address or fax number listed below.
New
Change
Business Name
Oregon Business Identification Number (BIN)
Address
Federal Employer Identification Number (FEIN)
City
State
ZIP Code
EFT Contact Person
Telephone Number
(
)
E-mail Address
Fax Number
(
)
I (we) contacted my (our) financial institution and confirmed that the financial institution can initiate
Automated Clearing House transactions that meet Oregon Department of Revenue requirements. For
verification, the department may contact:
Name of Financial Institution
Financial Institution Contact Person
Telephone Number
(
)
Check this box if these transactions will be funded from a non-US financial institution.
I (we) request that the Department of Revenue grant authority to the above named business to initiate Automated
Clearing House credit transactions to the bank account of the State of Oregon. I (we) understand transactions
must be in the National Automated Clearing House Association (NACHA) CCD+ format using the Tax Payment
(TXP) Banking Convention and may only be initiated for payment of Oregon Estimated Corporation Excise or
Income Taxes. I (we) understand that the above named business is responsible for paying the cost of initiating such
transactions that may be charged by the business’ financial institution. I (we) acknowledge that the origination of
ACH transactions to my (our) account must comply with the provisions of state and U.S. law. I (we) and the Oregon
Department of Revenue agree to abide by all applicable ACH operating rules in effect from time to time.
This agreement is to remain in full force and effect until the Oregon Department of Revenue has received written
notification from me (or either of us) of its termination so as to afford the interested parties a reasonable time to act
on it.
Authorized Signature
Title
Date
X
150-102-042-1 (Rev. 11-09)
Send your completed agreement to: EFT Coordinator
Administrative Services Division
Oregon Department of Revenue
PO Box 14725
Salem OR 97309-5018
Or fax it to: 503-947-2016
KEEP A COPY OF THIS AGREEMENT FOR YOUR RECORDS

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