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Authorization Agreement for

Electronic Funds Transfer and Disclosure Agreement

Page 2 of 2

Part IV ACH Debit Option

(Complete this section only if you select or are currently using the debit option.)

Complete the requested information regarding the ﬁ nancial institution to be used. If payments are to be debited to the taxpayer’s

account, the form must be signed and dated by a person in the taxpayer’s organization who is an authorized signatory on the account

speciﬁ ed below. If payments are to be debited to a payroll service’s account, the form must be signed and dated by a person in the

payroll service’s organization who is authorized to enter into this agreement on behalf of the payroll service and is an authorized

signatory on the account speciﬁ ed below. We will contact you with the payment instructions and the toll-free number for our Data

Collection Center.

Financial Institution Name:

Financial Institution Address:

Financial Institution City, State, Zip Code:

Account Name:

Account Type:

Checking

Savings

Account Number:

Financial Institution Routing/Transit Number:

I hereby authorize the Arizona Department of Revenue to process debit entries into the bank account speciﬁ ed above. These debits

will pertain only to electronic funds transfer payments the above-named taxpayer or their agent initiates for payment of the tax type(s)

speciﬁ ed above.

Taxpayer’s Authorized Signature

Title

Date

Payroll / Accounting Service Group’s Authorized Signature

Title

Date

Part V ACH Credit Option

(Complete this section only if you select or are currently using the credit option.)

I hereby request that the Arizona Department of Revenue grant authority for the above-named taxpayer or their agent (Part I) to initiate

ACH Credit transactions to the Department of Revenue bank account. It is understood that these transactions must be in the NACHA

CCD+ format using the Tax Payment Convention and may only be initiated for the tax type(s) speciﬁ ed in Part II.

Authorized Signature

Title

Date

Part VI Disclosure Agreement

(Complete this section only if an outside payroll / accounting service named in Part III or another

third party not named in Part III is being designated by the taxpayer indicated in Part I to receive taxpayer conﬁ dential

information from the Arizona Department of Revenue.)

By signing this form, the undersigned authorizes the Department to release conﬁ dential information relating to Arizona Department of

Revenue Authorization Agreement and Disclosure Agreement for Electronic Funds Transfer authorization to:

This form is not a Power of Attorney and does not grant the contact person(s) any power of representation. This disclosure

authorization is to remain in force until rescinded by the undersigned. By signing this form, I certify that I have the authority to execute

this authorization form on behalf of the above-mentioned corporation(s), limited liability company(ies), trust(s), partnership(s), and/or

individual(s).

Taxpayer’s Signature

Title

Date

This disclosure agreement automatically revokes all earlier EFT authorization agreements and disclosure agreements on ﬁ le with the

Arizona Department of Revenue. If you do not want to revoke a prior EFT authorization agreement and disclosure agreement,

check this box..................................................................................................................................................................................

You

attach a copy of any prior agreements you want to remain in effect.

MUST

ADOR 11-2056 (9/02)

NOTE: This form may be duplicated. Please make a copy for future use.

Form Ador 11-2056 - Authorization Agreement For Electronic Funds Transfer And Disclosure Agreement Page 2

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