Form Bfs-152 (02/2011) - Application For Electronic Funds Transfer - Form

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APPLICATION FOR ELECTRONIC FUNDS TRANSFER (EFT)

To be considered for participation in the Department of State’s Electronic Funds Transfer (EFT) program, please provide

the information requested below. Upon approval, your authorizing signature permits the Department of State to

electronically transfer funds from your financial institution to a State of Michigan account.

– PLEASE KEEP A COPY OF THIS APPLICATION FOR YOUR FILES –

NOTE: This application must be completed when you first apply to participate in the EFT program OR you

change banks OR you have a bank account number change. You may either mail or fax your application to:

Michigan Department of State

Revenue Accounting Section

7064 Crowner Drive

Lansing, MI 48918

FAX: (517) 373-1306

COMPANY NAME ______________________________________________________________________________________

ADDRESS ______________________________________________________________________________________________

CITY __________________________ COUNTY ___________________________ STATE ____________ ZIP ____________

TELEPHONE NUMBER (

) ____________________________ FAX NUMBER (

) ___________________________

DEALER NUMBER _____________ CONTACT PERSON ______________________________________________________

AUTHORIZATION FOR VARIABLE WITHDRAWALS -- AUTOMATED CLEARING HOUSE DEBITS

I hereby authorize the Department of State to make withdrawals from the account identified below at:

___________________________________________________ and authorize the DFI to charge such withdrawals to my listed account.

(Depository Financial Institution, hereinafter referred to as DFI)

Because these regular payments may vary in amount, the Department of State will provide a summary of all work processed.

If the purpose for withdrawal is restricted in any manner, such restriction is stated below. Adjusting entries to correct errors are also authorized. It is

agreed that these withdrawals and adjustments may be made electronically and under the Rules of the National Automated Clearing House

Association. This authorization will remain in effect until written notice of termination is given to the Department of State.

Please note that you are ineligible to pay by ACH if the bank account identified on the voided check/deposit ticket is funded or otherwise associated

with a foreign bank account to the extent that the payment transaction would qualify as an International ACH Transaction (IAT) under the NACHA

Rules.

DFI NAME

DFI ROUTING AND TRANSMIT

ACCOUNT NUMBER TO DEBIT

TYPE OF ACCOUNT

NUMBER

˜ CHECKING

PRINTED NAME OF AUTHORIZING PARTY ADDRESS CITY STATE ZIP