Form Ador 10366 - Authorization Agreement For Electronic Funds Transfer And Disclosure Agreement - For Credits Filers

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Arizona Department of Revenue • EFT Unit
DOR USE ONLY
1600 West Monroe, Room 225 • Phoenix, AZ 85007-2650
Credit
Fax: (602) 771-9913
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER AND DISCLOSURE AGREEMENT –
FOR CREDIT FILERS
• Parts I and II must be fi lled out completely and the form must be signed.
• This form is for ACH Credit Filers only.
• If you wish to use the ACH Debit Option, please register at
Part I: Taxpayer Information (required)
1 BUSINESS NAME
7 EFT CONTACT NAME
2 BUSINESS STREET ADDRESS 1
8 EFT CONTACT TITLE
3 BUSINESS STREET ADDRESS 2
9 BUSINESS PHONE NUMBER (with area code)
4 BUSINESS CITY
5 STATE 6 ZIP CODE
10 EFT CONTACT FAX NUMBER
Part II: ACH Credit Option ONLY
I hereby request that the Arizona Department of Revenue grant authority for the above-named taxpayer or their agent (Part I) to
initiate ACH credit transactions to the Department of Revenue bank account. It is understood that these transactions must be in
the NACHA CCD+ format using the Tax Payment Convention and may be initiated for the tax type(s) specifi ed in Part II.
Estimated Corporate Income Tax
Payroll Withholding Tax EIN:
Transaction Privilege & Use Tax
11
12
13
EIN:
AZ TPT No:
Part III: Disclosure Agreement
Check this box only if a third party not named on this form is being designated by the taxpayer indicated in Part I to receive
taxpayer confi dential information from the Arizona Department of Revenue. By signing this form, the undersigned authorizes the
department to release confi dential information relating to Arizona Department of Revenue Authorization Agreement and Disclosure
Agreement for Electronic Funds Transfer authorization to:
.
This Disclosure Agreement automatically revokes all earlier EFT authorization agreements and disclosure agreements on fi le
with the Arizona Department of Revenue. Check this box if you do not want to revoke a prior EFT authorization agreement and
disclosure agreement. You MUST attach a copy of any prior agreements you want to remain in effect.
Part IV: Signature
This form is not a Power of Attorney and does not grant the contact person(s) any power of representation. This disclosure
authorization is to remain in force until rescinded by the undersigned. By signing this form, I certify that I have the authority to execute
this authorization form on behalf of the above-mentioned corporation(s), limited liability company(ies), trust(s), partnership(s), and/or
individual(s).
Taxpayer’s Authorized Signature
Title
Date
Payroll / Accounting Service Group’s Authorized Signature
Title
Date
NOTE: This form may be duplicated. Please make a copy for future use.
ADOR 10366 (12/10)
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