Ach Credit Enrollment Form

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TENNESSEE DEPARTMENT OF REVENUE
ELECTRONIC FUNDS TRANSFER
ACH CREDIT ENROLLMENT FORM
Mandatory
RETURN BY FAX TO:
Voluntary Participation
STATE OF TENNESSEE
FAX NO. 615-532-2299
COMPANY NAME:
Co. Contact Person:
COMPANY ADDRESS:
Phone Number:
CITY/ STATE/ ZIP:
Fax Number:
ACCOUNT TYPE (Type of Tax): ____________________
FEIN:
______________
TN Tax Acct #: __________________________________
Signature
Title
Date
TENNESSEE DEPARTMENT OF REVENUE

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