DOR USE ONLY
Arizona Department of Revenue • EFT Unit
Mandatory
1600 West Monroe, Room 610 • Phoenix, AZ 85007-2650
Tel: (602) 542-2040 • 1-800-572-7037 • Fax: 1-602-542-3605
Voluntary
AUTHORIZATION AGREEMENT
FOR ELECTRONIC FUNDS TRANSFER AND DISCLOSURE AGREEMENT
Part I
Taxpayer Information (required)
1) Enter the taxpayer’s name exactly as it will appear on the return.
2) Enter the name, title and phone number of a person in the taxpayer’s organization that can be contacted if further information is
necessary.
Name:
EFT Contact:
Address 1:
Title:
Address 2:
Telephone: (
)
City, State, Zip Code:
E-mail:
Part II Tax Type/Payment Method and Agreement Information
Check and complete only each tax type/payment method that requires action: 1) Arizona Estimated Corporate Income Tax, 2)
Arizona Withholding Tax, 3) Arizona Transaction Privilege & Use Tax (TPT).
• When setting up an account, check the box next to the applicable tax type and payment method, write in the applicable taxpayer
identifi cation number, and check the Set Up Account box.
• When modifying an account, check the box next to the applicable tax type and payment method, write in the applicable taxpayer
identifi cation number, check the Modify Account box, and check the boxes for the bank information that needs to be modifi ed.
Indicate new banking information in Part IV.
Desired modifi cation effective date:
All Three Tax Types:
Check here if changing from debit to credit.
______________
1
Estimated Corporate Income Tax
2
Withholding (W/H) Tax
3
Transaction Privilege & Use Tax
Debit Method
Debit Method
Debit Method
Credit Method
Credit Method
Credit Method
Federal I.D. No. ________________
AZ W/H License No. ________________
AZ TPT License No. ________________
Set Up Account
Set Up Account
Set Up Account
Modify Account
Modify Account
Modify Account
Change Bank Account Number
Change Bank Account Number
Change Bank Account Number
Change Bank R/T Number
Change Bank R/T Number
Change Bank R/T Number
Part III Outside Payroll / Accounting Service Information
1) Enter the service name and address.
2) Enter the name, title and phone number of a person at the service that can be contacted if further information is necessary.
Name:
Contact:
Address 1:
Title:
Address 2:
Telephone: (
)
City, State, Zip Code:
Continued on Page 2
ADOR 11-2056 (9/02)