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Form D-155 - Registration Application - Motor Fuel Edi Or Web Based Filing Electronic Funds Transfer (Eft) Page 2

INSTRUCTIONS FOR COMPLETING

REGISTRATION APPLICATION

Name and Address:

Should be mailing address for EFT/EDI/WEB related information.

Tax Type:

Type of Motor Fuel License.

SC File #:

SC license number. Each license number should be registered separately.

Filing Type:

This is to indicate EDI filing or WEB Based filing.

Tax Software Vendor:

Which software vendor (EDI only) are you using? Vendor must be certified

with SC.

FEIN:

Federal Identification Number

Tax Return Contact Person:

The person responsible for filing the EDI or WEB Based return.

Payment Contact Person:

The person responsible for making the EFT or on-line payment.

ACH Debit

The taxpayer hereby authorizes the SC Department of Revenue to present

debit entries to the bank account given. These debits will pertain only to

EFT payments the taxpayer has authorized through the debit procedures.

ACH Credit

To initiate an ACH Credit, you must be set up to do so with your bank. If

you wish to pursue this option, we recommend you contact your bank first

to determine what ACH origination services they offer and the costs. If you

have any questions concerning this procedure, please call your banking

institution.

If you select this method, the SC Department of Revenue will provide the

State's bank account number ABA(American Bank Association)

Routing/Transit number necessary to initiate an ACH Credit. This will be

mailed to you after you have registered with the Department to use this

method.

First Signature

By signing here you agree to allow SC Department of Revenue to debit

your account or to use the required CCD+ detail record for ACH Credit

transmission.

Second Signature

By signing here, you agree to comply with ANSI X.12 standards or use the

State's website for final transmission to the SC Department of Revenue.

11122025

Form D-155 - Registration Application - Motor Fuel Edi Or Web Based Filing Electronic Funds Transfer (Eft) Page 2