Form Ef-101 - Authorization Form For Electronic Funds Transfer - Kansas Division Of Taxation

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Division of Taxation
Phone: 785-296-6993
915 SW Harrison St
FAX: 785-296-0153
Topeka KS 66625-2007
Samuel M. Williams, Secretary
Department of Revenue
Sam Brownback, Governor
AUTHORIZATION FORM FOR ELECTRONIC FUNDS TRANSFER
(Complete, sign, and mail or fax this form to the Department of Revenue.)
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N N N N e e e e w w w w A A A A c c c c c c c c o o o o u u u u n n n n t t t t
B B B B a a a a n n n n k k k k C C C C h h h h a a a a n n n n g g g g e e e e ­ ­ ­ ­ E E E E f f f f f f f f e e e e c c c c t t t t i i i i v v v v e e e e D D D D a a a a t t t t e e e e
T T T T a a a a x x x x A A A A c c c c c c c c o o o o u u u u n n n n t t t t I I I I n n n n f f f f o o o o C C C C h h h h a a a a n n n n g g g g e e e e
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Office Use Only
_________________
Kansas Tax Account Number
Filing Freq. _____________________
License Number ___________
( Mineral Tax and Motor Fuel only )
PIN Number ____________________
Choose all tax types that apply:
REG. ____
DATABASE ________
○
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Mineral
Retail Compensating
Consumers' Compensating Use
○
○
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Corporate Income
Motor Fuel
Retail Sales
ADD. ____
MAIL DATE _______
○
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Franchise
Privilege
Withholding
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Gallonage
Taxpayer Information (Please type or print) Email:
_____________________________________________
◦
____________________
Name ______________________________________
EFT Contact
Address
____________________________________
Phone Number _________________________
City , State Zip
______________________________
FAX Number _______________________
Payroll/Tax Services: Email:_____________________________________________________________
If you contract with a payroll/tax service or if you are with a service preparing this form for a taxpayer, please provide the name of the service and the
contact person.
Service Name:
Contact Person
:
Contact Phone Number
:
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ACH Debit Option
If ACH Debit is chosen, the information you provide the Kansas Department of Revenue gives us the authorization to debit your bank for the tax(es)
identified above. Only you can initiate a debit by calling the state’s system and indicating the amount of tax to be paid by electronic funds transfer.
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:
Account Type: (check one)
Checking
Savings
NOTE
PLEASE ENCLOSE A V OIDED C HECK FOR V ERIFICATION
Bank Name:
Bank Contact
:
Phone Number:
____________________________
Routing # :
Account # :
○
ACH Credit Option
If ACH Credit is chosen, you will be responsible for contacting your bank, indicating the amount you want sent and having the transaction completed
timely for funds to be received by the Kansas Department of Revenue on or before the EFT due date. I hereby request the Kansas Department of
Revenue to grant authority for the above named taxpayer to initiate ACH credit transactions to the State Treasurer’s bank account. I understand these
must be in the NACHA CCD+ format using the TXP convention.
Authorized Signature:
Signature :__________________________________________
Date
:
Print Name:
Title:
EF-101 (Rev. 07/11)

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