Form 4041 - Motor Fuel Electronic Funds Transfer (Eft) Debit Application

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Michigan Department of Treasury

Reset Form

4041 (Rev. 06-12)

Motor Fuel Electronic Funds Transfer (EFT) Debit Application

Issued under P.A. 122 of 1991, as amended. Filing is mandatory if you wish to pay by EFT Debit.

Use this form to notify Treasury that you intend to pay your Motor Fuel taxes by EFT Debit. You may begin electronic payment after you receive our

approval and receive instructions for transmitting.

Taxpayer Idenification Number

Taxpayer Name and Address

Contact Person Telephone Number

Contact Person

Contact Person Fax Number

E-Mail address - Enter e-mail address to receive electronic confirmation of your web payment

Tax Type: Motor Fuel Tax Code: 05000

AUTHORIZATION FOR EFT DEBITS

If you are interested in making Motor Fuel Tax payments using the Electronic Funds Transfer (EFT) debit method, you must give written permission to

access your bank account to withdraw the funds you authorize. Please do this by signing below.

I authorize the State of Michigan and its authorized contractor to make variable withdrawals by electronic transfer from the designated financial

institution and account. I understand that only the withdrawals I authorize will be made and that this process is protected by a password and a user

code. I understand that I may cancel this authorization at any time by sending a written notice to the address noted below. I agree to comply with the

National Automated Clearing House Association Rules and Regulations about electronic transfers as they exist on the date of my signature on this

form or as subsequently adopted, amended, or repealed. Michigan law governs electronic funds transactions authorized by this agreement in all

respects except as otherwise superseded by federal law. If multiple signers are required to authorize a withdrawal of funds, all must sign this form.

Signature of Responsible Officer

Title

Date

Additional Signatures (if needed)

Please be aware of corporate officer liability as provided in Michigan Compiled Laws 205.27a(5):

“If a corporation, limited liability company, limited liability partnership, partnership or limited partnership liable for taxes administered under this

act fails for any reason to file the required returns or to pay the tax due, any of its officers, members, managers, or partners who the department

determines, based on either an audit or an investigation, have control or supervision of, or responsibility for, making the returns or payments is

personally liable for the failure.”

CORPORATE OFFICER CERTIFICATION

This form will not be processed for corporations unless this section is completed.

Signature of Officer Responsible for Reporting and/or Paying Michigan Taxes

Date

Type or Print Name

Title

This corporate officer certification must be resubmitted when there is a change in the officer responsible for filing and/or paying Michigan taxes. Mail

this form to the Michigan Department of Treasury for approval. We will sign it and return it to you. You will receive instructions from our contractor for

filing electronic payments.

SECURITY

The security question is required to complete the processing of your application. Please retain a copy of your answer. A correct response is required

when contacting Treasury’s authorized contractor or completing certain updates to your account. You may change the security question and/or

response after successfully accessing your account.

What school did you attend for sixth grade?

If you have any questions, contact the Michigan Department of Treasury at (517) 636-4600.

Return this from to:

Michigan Department of Treasury

PO Box 30474

Lansing MI 48909-7974

Fax: (517) 636-4593