Fillable Form 5131 - Cigarette Tax Ach Transfer Agreement printable pdf download

Form 5131 - Cigarette Tax Ach Transfer Agreement

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FORM

MISSOURI DEPARTMENT OF REVENUE

5131

TAXATION DIVISION

CIGARETTE TAX ACH TRANSFER AGREEMENT

(REV. 03-2009)

Department of Revenue City/County Tax Code (DOR USE ONLY):

TYPE OF AGREEMENT (CHECK ONE):

NEW

CHANGE

CANCEL

CITY/COUNTY NAME

CITY/COUNTY ADDRESS

Please complete this form and return to the Missouri Department of Revenue, Administration Division, Investment and Cash

Management Section, P.O. Box 87, Jefferson City, Missouri 65105-0087. Please call (573) 522-5628 with any questions concerning

this form.

The agreement must be received by the Department on or before the fifteenth (15th) day of the month prior to the date the

agreement becomes effective, to allow sufficient time for processing.

We acknowledge that the Department reserves the right to provide distribution by check or other means as it deems necessary.

The undersigned designate the following as the account to which the Department should credit ACH of the above-mentioned tax:

1. RECEIVING BANK NAME

RECEIVING BANK ADDRESS

2. RECEIVING BANK ROUTING NUMBER (ABA)

3. CITY/COUNTY ACCOUNT NAME (AT THE BANK)

4. CITY/COUNTY ACCOUNT NUMBER (AT THE BANK)

ATTACH A VOIDED DEPOSIT TICKET OR VOIDED CHECK AS VERIFICATION OF THE ABOVE INFORMATION.

Two (2) city/county official authorized signatures are required, one of which must be the city/county clerk, treasurer, col-

lector or finance director.

Under penalties of perjury, we, as authorized representatives of the political jurisdiction for the tax described above, declare that the above informa-

tion is, to the best of our knowledge and belief, true, correct and complete. (Affix the corporate seal of the city/county.)

LOCAL OFFICIAL SIGNATURE

TITLE

LOCAL OFFICIAL SIGNATURE

TITLE

LOCAL OFFICIAL NAME (TYPE OR PRINT)

TELEPHONE NUMBER

FAX NUMBER

DO NOT WRITE IN THIS AREA. DEPARTMENT OF REVENUE USE ONLY.

SIGNATURE

TITLE

DATE