Authorization Agreement Electronic Funds Transfer Form printable pdf download

Authorization Agreement Electronic Funds Transfer Form

RICHARD CORDRAY

TREASURER OF STATE

Authorization Agreement

Electronic Funds Transfer

PLEASE COMPLETE ONE AGREEMENT PER OHIO TAX ID NUMBER

Part I TAXPAYER INFORMATION (REQUIRED)

Federal ID Number

Please type or print information

Taxpayer Name

Contact Person

Mailing Address (Street Number, Box Number)

Telephone Number

City, State, Zip Code

Fax Number

E-mail Address

Payroll Service

Part II TAX TYPE

□ NEW EFT ACCOUNT

□ MODIFY EFT ACCOUNT

OHIO TAX ID NUMBER

□ Sales OR Use Tax

□ Public Utilities Tax

_________________________

□ Corporate Franchise Tax

□ Withholding Tax

□ Motor Vehicle Fuel Tax

□ Municipal

Use Part III for bank account changes

Part III ACH DEBIT OPTION (Taxpayer phones in tax payment)

Financial Institution Name

Type of Account

□ Checking

□ Savings

Transit & Routing Number

Bank Account Number

I hereby authorize Ohio Treasurer Richard Cordray’s Office to process ACH Debit entries from the bank account specified above.

This debit will pertain only to Electronic Funds Transfer Payments for the above named taxpayer.

Authorized Signature

Date

Part IV ACH CREDIT OPTION (Taxpayer initiates payment through their own bank)

I hereby request Ohio Treasurer Richard Cordray’s Office to grant authority for the above-named taxpayer to initiate ACH Credit

Transactions to Ohio Treasurer Richard Cordray’s Office bank account. It is understood that these transactions must be in the NACHA

CCD+ format using the TXP Payment Convention and may only be initiated for the tax type specified above.

Authorized Signature

Date

MAIL: Ohio Treasurer Richard Cordray

Questions: Ohio Treasurer Richard Cordray

Attn: Electronic Funds Department

EFT Help Line

30 East Broad Street, 9

Floor

1-877-EFT-OHIO

Columbus, Ohio 43215-3461

FAX: (614) 752-5377

Revised 10/2005

Authorization Agreement Electronic Funds Transfer Form

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