Form Dr 1011 - Authorization Agreement For Automatic Deposits (Ach Credits)
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1DR 1011 (07/16/12)
COLORADO DEPARTMENT OF REVENUE
taxpayeR seRvice Division
Authorization Agreement
for Automatic Deposits (ACH Credits)
account number:
i (we) hereby authorize the Department of ____________________________________________________________,
state of colorado, hereinafter called state, to initiate credit entries, and if necessary, debit entries and adjustments for any
credit entries in error to our bank account indicated below and the Bank named below, hereinafter called DepositoRy,
to credit and/or debit the same to such account.
Check Tax Liability Needed
city
county Lodging
e 911
public safety improvement
short-term Rental
special ownership tax
county
cigarette
class a
Mass transit
Rural transportation authority
class F
Local Marketing
Multiple Housing authority
Metropolitan District
Regional transportation District
Local improvement District
Scientific & Cultural Facilities District
entity name
Federal e.i.n. number
___ ___ – ___ ___ ___ ___ ___ ___ ___
address (Mail)
street
city
state
Zip
Depository name
Branch address (street)
city
state
Zip
Depository transit / Routing number:
Depository account number:
checking
savings
(Please attach deposit slip)
This agreement is to remain in full force and effect until the STATE has received written notification from the ENTITY of
its termination in such time and manner to afford state and DepositoRy a reasonable opportunity to act on it. it is the
responsibility of the ENTITY to fill out a new agreement if the ENTITY changes banks or accounts.
Date
phone number
authorized signature
title
authorized signature
title
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Parent category: Financial