Form D-155 - Registration Application - Motor Fuel Edi Or Web Based Filing Electronic Funds Transfer (Eft)

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STATE OF SOUTH CAROLINA
1350
1350
D-155
DEPARTMENT OF REVENUE
REGISTRATION APPLICATION - MOTOR FUEL
(Rev. 1/3/12)
EDI OR WEB BASED FILING
1112
ELECTRONIC FUNDS TRANSFER (EFT)
Tax Type:
NAME AND ADDRESS (Please print)
SC File#
(Each File # should be filed separately)
Check one: EDI
Web
Software Vendor (EDI Only)
FEIN
CONTACT PEOPLE
Tax Return Contact
Payment Contact
(if different)
Contact Name
Contact Name
Telephone #
Fax #
Telephone #
Fax #
E-mail
E-mail
PAYMENT SELECTED & AUTHORIZATION
Two (2) payment options available for Electronic Funds Transfer for both EDI and Web Based returns are ACH Debit or
ACH Credit. Indicate the option you select by checking the appropriate box below and signing. Please see the
instruction page for further details.
ACH Debit (EDI Only)
OR
ACH Credit
ACH Debit (Web Based)
Signature
Title
Date
EDI RETURN AUTHORIZATION
The taxpayer hereby agrees to use the ANSI X.12 standards and version in place at the time of each transmission and
authorizes the electronic filing of the tax return through the State's designated agent.
Signature
Title
Date
Return this form to: SC Department of Revenue, Electronic Services Help Desk, Columbia, SC 29214-0016 or Fax to
(803) 896-1779. If you have any questions, call 1-800-476-0311 or in Columbia area, (803) 896-1715.
11121027

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