Form Dr 1011 - Authorization Agreement For Automatic Deposits (Ach Credits) For Local Governments, Authorities And Districts

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*131011==19999*
DR 1011 (08/30/13)
COLORADO DEPARTMENT OF REVENUE
Denver CO 80261-0009
303-866-3211 Fax
Authorization Agreement
for Automatic Deposits (ACH Credits)
for Local Governments, Authorities and Districts
Account Number:
I (we) hereby authorize the Department of Revenue, 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
Local Improvement District
Regional Transportation District
Scientific & Cultural Facilities District
Public Safety Improvement
County Lodging
County
Short-Term Rental
E 911
Mass Transit
Cigarette
Special Ownership Tax
Local Marketing
Rural Transportation Authority
Class A
Metropolitan District
Multiple Housing Authority
Class F
Entity Name
FEIN
Mailing Address
City
State
Zip
Depository Name
Branch Address
City
State
Zip
Routing Number
Type:
Checking
Savings
Direct
Deposit
Account Number
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
(MM/DD/YY)
(
)
Authorized Signature
Title
Authorized Signature
Title

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