Form Eft - Authorization Agreement For Electronic Funds Transfers
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1Software Vendor Final 10.10.13
FORM EFT
Please Complete:
Name of Business
Tax Type: Check type(s)
Maryland Central Registration Number
Comptroller of Maryland
Withholding
Authorization Agreement for
Federal Employer Identification Number
Corporation Income Tax
Electronic Funds Transfers
( Pass Through Entities are
New
not eligible.)
Motor Fuel Tax Account Number (if applicable)
Revision: Effective Date
__________
Motor Fuel Taxes
Please allow 10 business days for revisions.
This section must be completed by all taxpayers
C
Primary EFT contact person ___________________________________________________________________________
O
N
Address ______________________________________________________________________________________
T
A
___________________________________________________________________________________________________
C
City
State
ZIP code
Telephone number
T
A
Secondary EFT contact person _____________________________________________________________________
P
E
Address ______________________________________________________________________________________
R
S
O
_____________________________________________________________________________________________
City
State
ZIP code
Telephone number
N
(S)
_____________________________________________________________________________________________
Signature of owner, partner, or officer
Title
Date
CHOOSE ONLY ONE OF THE TWO PAYMENT OPTIONS BELOW
This section to be completed only if you choose the ACH DEBIT OPTION
If ACH Debit is chosen, you authorize the Comptroller of Maryland to present the debit entries to your bank for the tax
identified above. Only you can initiate a debit by calling the State’s Service Bureau and indicating the amount of tax to
be paid by electronic funds transfer.
A
Bank name
________________________________________________________________________________________________
C
H
Bank address
______________________________________________________________________________________________
B
D
__________________________________________________________________________________________________________
E
City
State
ZIP code
B
I
Bank account number
Bank routing/transfer number
___________________________
_________________________________
T
Checking
Savings
__________________________________________________________________________________________________________
Signature of owner, partner or officer
Title
Date
This section to be completed only if you choose the ACH CREDIT OPTION
An AUTHORIZED REPRESENTATIVE of your bank must complete and sign this section confirming that you and your
bank are capable of initiating ACH CREDITS in the required CCD + TXP format.
A
Bank name
________________________________________________________________________________________________
C
H
Bank address
______________________________________________________________________________________________
C
C
__________________________________________________________________________________________________________
R
City
State
ZIP code
E
__________________________________________________________________________________________________________
D
Printed name of bank representative
Telephone number
I
T
__________________________________________________________________________________________________________
Signature of bank representative
Date
This form must be completed and faxed to 410-260-6214 or mailed to:
Electronic Funds Transfer Program, P.O. Box 1509, Annapolis, MD 21404-1509
1
COM/RAD-072
13-49
Rev. 06/13
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