Form De 26 - Electronic Funds Transfer (Eft) State Data Collector Program - Vendor (Third Party) New Enrollment Request Form

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Department Use Only
ELECTRONIC FUNDS TRANSFER (EFT)
STATE DATA COLLECTOR PROGRAM - VENDOR (THIRD PARTY)
NEW ENROLLMENT REQUEST FORM
(See reverse for instructions.)
SECTION I: Employer information must be completed.
Business Name
Employer Account Number
Business Mailing Address (Number, Street, or Box Number)
Business Phone Number
Business Mailing Address (City, State, ZIP Code)
EFT Contact Person
EFT Contact Phone
SECTION II: Enrollment Authorization
I hereby authorize designated financial agents of the Employment Development Department (EDD) to
enroll the Employer Account Number, indicated above, in the state data collector program.
Important: A form without the signature will be returned unprocessed.
Signature
Title
Print Name
Date
Phone Number
Fax the completed form to 916-654-7441, or
Mail to:
e-Pay Unit, MIC 15A
Employment Development Department
PO Box 826880
Sacramento, CA 94280-0001
If you have questions regarding this form, please call the e-Pay Unit at 916-654-9130.
DE 26 Rev. 10 (6-16) (INTERNET)
Page 1 of 2
CU

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