Form 150-206-029 - Ach Debit Authorization Agreement And Application For Combined Payroll Tax And Assessment Page 7

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Clear Form
Department of Revenue Use Only
Date Received
ACH DEBIT AUTHORIZATION AGREEMENT AND APPLICATION
FOR COMBINED PAYROLL TAX AND ASSESSMENT
• Please type or print clearly in black ink.
• Check the correct box to indicate whether this is a new application or a change.
• Attach a letter from your financial institution or a voided check to your completed application.
• 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
(
)
Business Checking Account
I (we) hereby authorize the Oregon Department of Revenue to debit my (our):
Business Savings Account and the financial institution named below upon initiation by the above name
or
entity in payment of Oregon Combined Payroll Tax and Assessments. 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.
Check this box if these transactions will be funded from a non-US financial institution.
Financial Institution
Branch Name or Address
City
State
ZIP Code
Account Number
Routing Number
Business Name (as it appears on the financial institution account)
This agreement is to remain in full force and effect until the 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.
X
Name (typed or printed)
Signature
Date
X
Name (typed or printed)
Signature
Date
—You must attach a voided check or a letter from your financial institution to your completed application—
150-206-029-2 (Rev. 11-09)
Send your completed agreement (with attachment) 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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