Authorization Agreement Electronic Funds Transfer Form printable pdf download

Authorization Agreement Electronic Funds Transfer Form

KEVIN L. BOYCE

TREASURER OF STATE

Authorization Agreement

Electronic Funds Transfer

PLEASE COMPLETE ONE AGREEMENT PER FEDERAL ID NUMBER

Part I TAXPAYER INFORMATION (REQUIRED)

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

Part II TAX TYPE

□ NEW EFT ACCOUNT

□ MODIFY EFT ACCOUNT

Financial Institution Federal ID Number

_________________________

□ IOLTA

Use Part III for bank account changes

Part III ACH DEBIT OPTION (Financial Institution phones in payment)

Financial Institution Name

Type of Account

□ Checking

□ Savings

Transit & Routing Number

Bank Account Number

I hereby authorize Ohio Treasurer Kevin L. Boyce’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 (Financial Institution initiates payment)

I hereby request Ohio Treasurer Kevin L. Boyce’s Office to grant authority for the above named Financial Institution to initiate ACH

Credit Transactions to Ohio Treasurer Kevin L. Boyce’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 Kevin L. Boyce

Questions: Ohio Treasurer Kevin L. Boyce

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 05/2007

Authorization Agreement Electronic Funds Transfer Form

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