Form De 26 - Electronic Funds Transfer Authorization Agreement

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Department Use Only
Location
Registration Date
ELECTRONIC FUNDS TRANSFER
AUTHORIZATION AGREEMENT
See reverse for instruction
SECTION I
A. Business Name
B. Employer Account Number
C. Business address (Number, Street, Box Number, City, State, Zip code)
D. Business Phone
(
)
E. EFT Contact Person
Title
Phone Number
(
)
Fax Number
E-Mail Address
(
)
SECTION II
ACH Debit
IMPORTANT: Attach a voided check or bank specification sheet
A. Bank Name
B. Bank Account Number
C. Routing Transit Number
D.
Checking
Savings
E. For bank account changes only, complete the following and Fax to (916) 654-7441:
Settlement date of your last payment
Due Date of your next Payment
Will your old and new bank accounts be open with funds until completion of this bank change?
Yes
No
SECTION III
ACH Credit
You are authorizing your financial institution to transfer funds from your bank account to the
Employment Development Department’s bank account.
SECTION IV Authorization
Please read the following Authorization Agreement:
–
ACH Debit
I hereby authorize designated Financial Agents of the EDD to initiate debit entries to the financial institution account
indicated above, for payments owed to the EDD upon request by taxpayer or his/her representative, using the ACH debit method.
–
ACH Credit
I hereby authorize the EFT contact person and the financial institutions involved in the processing of my Electronic
Funds Transfer payments to receive confidential information necessary to effect my enrollment in the EFT program and to answer
inquiries related to my payments.
A. Taxpayer Signature
B. Title
C. Date
Return to Attention: EFT Unit, MIC 15 / Employment Development Department / P.O. Box 826880 / Sacramento CA 94280-0001
Phone: (916) 654-9130 / Fax: (916) 654-7441
DE 26 Rev. 6 (8-02) (INTERNET)
Page 1 of 2
CU

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