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Eft Enrollment Form For New Enrollment Or Modify Original Enrollment - Idaho State Treasurer

State of Idaho

Office of the State Treasurer

EFT Enrollment Form – Please print or type.

Please retain a copy of this form for your records. Return the completed form to the State Treasurer's Office.

NEW ENROLLMENT

MODIFY ORIGINAL ENROLLMENT

EFT Tax Payment Type available:

Department of Labor (Tax Type 13090)

Indicate which method you will use in sending your payment.

Automated Clearing House (ACH) Debit

Automated Clearing House (ACH) Credit

Employer Account Number (10): __ __ __ __ __ __ __ __ __ __

Company Name (25): __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Contact (25): __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Address (25): __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

City (15): __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

State (2): __ __

Zip: __ __ __ __ __ - __ __ __ __

Telephone: (__ __ __) __ __ __ - __ __ __ __

Financial Institution Information (Debit method only)

If you are using the ACH Debit System, please include a voided check or a letter from your financial institution in order to

verify the American Bank Association Number and the Bank Account Number.

Transit (Routing) / ABA Number (9): __ __ __ __ __ __ __ __ __

Account Number (up to 17 digits): __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __

Checking

Savings

Other

__________________________

(Explain)

Authorization FOR DEBIT METHOD ONLY:

I (we) hereby authorize the financial institution indicated above to debit the above account, and transfer the debited

amount to the Idaho State Treasurer's account.

Name

Title

Signature

Date

Eft Enrollment Form For New Enrollment Or Modify Original Enrollment - Idaho State Treasurer