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Authorization Agreement Form For Electronic Funds Transfer Form. This is a Indiana form and can be use in Department Of Revenue Statewide.
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Tags: Authorization Agreement Form For Electronic Funds Transfer, EFT-1, Indiana Statewide, Department Of Revenue
EFT-1
Indiana Department of Revenue
State Form 50110
(R6 / 06-08)
Indiana Taxpayer ID #:
Authorization Agreement Form
For Electronic Funds Transfer
_ _____________________________
(Must Be 13 Digits) See Special Instructions on Back.
Date: _ __________________
Business Name: _ __________________________________________________________________________
Name and Telephone Number of Individual in your Organization that Revenue may contact regarding EFT
Contact Person:
_____________________________________________
(Please print)
Address:
_____________________________________________
o EFT Required
(Not a Bank contact)
City, State, ZIP:
_____________________________________________
Telephone:
or
o Voluntary
_____________________________________________
Please complete a separate form for each tax type selected.
o Sales (RST)
o
Financial Institution (FIT)
o Fee (TIF)
Tire
o
Utility Receipts Tax (URT)
o
Withholding (WTH)
o
Gasoline Distributors
o
Prepaid Sales on Gasoline (PPD)
o
Special Fuel Tax (SFT)
o
Corporate Income (COR)
o
Streamlined Sales Tax (SST)
o II Gaming (TTG)
Type
o
Cigarette Tax (CIG)
(MFT)
Please choose an EFT method. If you choose ACH Debit, you must also complete the banking information portion of this
form, and attach a copy of a voided check to verify the banking information.
o Credit
ACH
o Debit* (Complete bank information)
ACH
Bank
Do not use this form to register for INtax. Visit
www.intax.in.gov
ABA#: ___________________________
(Transit Routing Number)
o
Checking
Your Account #: _________________________
or
o
Savings
(With the above bank)
_________________________________________
Authorized Signature
____________________
Title
_ ______________
Date
*If ACH Debit is chosen, the taxpayer hereby authorizes the Indiana Department of Revenue to present debit entries
into the bank account referenced above as required by Indiana Law. These debits will pertain only to Electronic
Funds Transfer payments that the taxpayer has initiated.
,
This form may be faxed or mailed.
Fax # ..................(317) 232-1851
Questions? . ......(317) 232-5500
EFT Section, Room N248, MS 103
Indiana Department of Revenue
100 N. Senate Ave.
Indianapolis, IN 46204-2253
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Completing the EFT-1 (Authorization Agreement)
Indiana TID# - Enter your 13 digit Indiana TID#. Your Indiana TID# is not your Federal ID#, with the
exception of Corporate Income, Financial Institution, and Utility Receipts Taxes.
Taxpayers registering for EFT to remit Corporate Income, Financial Institution, or Utility Receipts
Taxes will use their nine digit Federal ID# plus four additional digits at the end as assigned by the
Department. If you do not know the last four digits, contact the EFT Section at (317) 232-5500, or only
enter the nine digit number and we will provide the four additional digits required for EFT payments
on your confirmation letter.
Other tax types will use a 13-digit number as assigned by the Department. Taxpayers registering for
EFT to remit Retail Sales/Use Tax, Employers’ Withholding Tax, or Prepaid Sales Tax on Gasoline
can find the 13-digit number by referring to the account number printed on their tax payment coupons,
minus the final (14th) digit.
Streamlined Sales Tax EFT ID numbers - EFT Taxpayer Identification for Streamlined Sales Taypayer
is the Streamlined Sales Account number assigned in the Streamlined Sales Registration. The Streamlined
Sales identification number should be aligned to the left of the field, therefore the number would be
‘S99999999’. The Certifiied Service Provider’s (CSP) identification number can be used in the future when
Indiana accepts the bulk payment from Certified Service Providers. The identification number would be
formatted as “CSP999999’.
Tax Type - Please complete and submit a separate EFT-1 form for each tax type for which you are registering
for EFT.
Bank Information - This section only needs to be completed by those taxpayers selecting the ACH Debit
method. You must indicate whether the account is checking or savings. Remember the ABA/Transit routing
number must be nine digits. Note: You cannot have multiple accounts for a single tax payment. Please
verify the accuracy of the bank information entered.
Taxpayer Contact - Enter the name and entire address of the person who should be contacted with
information concerning EFT tax payments, or if there is a problem with EFT payments. Do not enter the
name of someone at your bank. We must have a taxpayer contact. Tax service providers may enter their
contact information if they have power of attorney to represent the taxpayer. The contact telephone number
must also be provided.
Required or Voluntary - Are you registering for EFT because you are required by law, or are you a
voluntary participant in the EFT program?
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