Authorization Agreement For Electronic Funds Transfer (Eft) Of Lwc Unemployment Tax Payments Form - Louisiana Workforce Commission

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Authorization Agreement for
Electronic Funds Transfer (EFT) of
LWC Unemployment Tax Payments
FOR ACH CREDIT AUTHORIZATION ONLY
New Application
Update
Employer Name or Authorized Agent
*State ID#.
Federal ID#.
1ST Contact Person
Telephone
2nd Contact Person
Telephone
Mailing Address for EFT purposes (Street Address, Box number)
Signature
Title
Date
* When filing for multiple employers, attach listing in the format below or list the
State ID#, Federal ID#, and DBA Name in the space provided below.
State UI No.
Federal Id No.
DBA (doing business as)
123456-7
99-9999999
ABC Company Inc.
Mail/ Fax Agreement To:
Fax(225) 342-5822/Phone(225)342-2955
Louisiana Workforce Commission
Office of Unemployment Insurance Administration
EFT Processing/UI Accounting
P. O. Box 94100
Baton Rouge, LA 70804-9186
Last Rev.(07/25/08)

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