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Form Ador 11-2056 - Authorization Agreement For Electronic Funds Transfer And Disclosure Agreement

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.

______________

Estimated Corporate Income Tax

Withholding (W/H) Tax

Transaction Privilege & Use Tax

Debit Method

Credit Method

Federal I.D. No. ________________

AZ W/H License No. ________________

AZ TPT License No. ________________

Set Up Account

Modify Account

Change Bank Account 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)

Form Ador 11-2056 - Authorization Agreement For Electronic Funds Transfer And Disclosure Agreement

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