Form Boe-555-Lj - Eft Authorization Agreement For Local Jurisdictions

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BOE-555-LJ (FRONT) REV. 2 (1-12)
STATE OF CALIFORNIA
EFT AUTHORIZATION AGREEMENT FOR LOCAL JURISDICTIONS
BOARD OF EQUALIZATION
Please type or print clearly in ink.
See reverse for complete instructions.
SELECT ACTION REQUESTED
SELECT TAX PROGRAM
New EFT Account
1% Local Tax
Change EFT Bank Account – (see instructions)
¼% (County) Transportation Fund
Cancel EFT
Add-on (Special District) Tax
SECTION I
NAME OF LOCAL JURISDICTION OR SPECIAL DISTRICT (payee)
TAX AREA CODE
CONTACT PERSON (name and title)
EMAIL ADDRESS
MAILING ADDRESS
CITY, STATE, ZIP
CONTACT PHONE NUMBER
CONTACT FAX NUMBER
SECTION II
The State Controller’s Office, on behalf of the State Board of Equalization (BOE), is hereby authorized to make direct
deposit (EFT) of any amounts distributed pursuant to the Bradley-Burns Uniform Local Sales and Use Tax Law or the
Transactions and Use Tax Law less any mandatory withholding or deductions therefrom to the designated bank account
identified below. If the designated EFT account is a checking account, a voided check or copy must be attached to the
completed authorization agreement. If the account is a savings or other deposit-only account, an account confirmation
from the bank must be attached. The voided check or confirmation will be used to verify the bank account and transit
routing numbers.
BANK NAME
BANK ACCOUNT NUMBER (not to exceed 17 digits)
TRANSIT ROUTING NUMBER
TYPE OF ACCOUNT
CHECKING
SAVINGS
IMPORTANT
Payee agrees that in the event that the payee owes a debt determined either by court order, or otherwise by operation of
law, and for which the BOE has been notified according to law, to make repayments by deductions from Local Sales and
Use Tax transmittals, the payee will be removed from the EFT program until the debt is extinguished.
I affirm that deposits received from the BOE are not subject to being transferred to a foreign financial institution.
SIGNATURE
TITLE
DATE
Return this form to:
Board of Equalization
Local Revenue Allocation Unit
Warrant Desk
P.O. Box 942879, MIC:27
Sacramento, CA 94279-0027
FAX 916-324-8117
For EFT assistance call 916-324-1386
This information is confidential and not for public release.
CLEAR
PRINT

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