Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Authorization Form For Electronic Funds Transfer Form. This is a Kansas form and can be use in Alcohol Beverage Control Statewide.
Loading PDF...
Tags: Authorization Form For Electronic Funds Transfer, EF-101, Kansas Statewide, Alcohol Beverage Control
Division of Taxation
915 SW Harrison St
Topeka KS 66625-2007
Nick Jordan, Secretary
Steve Stotts, Director of Taxation
Department of Revenue
Toll Free: 1-800-525-3901
Phone: 785-296-6993
FAX: 785-296-0153
www.webtax.org
Sam Brownback, Governor
AUTHORIZATION FORM FOR ELECTRONIC FUNDS TRANSFER
(Complete, sign, and mail or fax this form to the Department of Revenue.)
○ New Account
Change○ Bank Change- Effective Date ________________ ○ Tax Account Info Change
Kansas Tax Account Number _________________
License Number ___________ ( Mineral Tax and Motor Fuel only )
Office Use Only
Filing Freq. _____________________
PIN Number ____________________
Choose all tax types that apply:
○
○
○
Consumers Compensating Use
Corporate Income
Franchise
○ Gallonage
○
○
○
Mineral
Motor Fuel
Privilege
○ Retail Compensating
○ Retail Sales
○ Withholding
REG. ____
DATABASE ________
ADD. ____
MAIL DATE _______
Taxpayer Information (Please type or print)◦ Email:_____________________________________________
Name ______________________________________ EFT Contact____________________
Address ____________________________________ Phone Number _________________________
City , State Zip ______________________________ FAX Number _______________________
Payroll/Tax Services: Email:_____________________________________________________________
If you contract with a payroll/tax service or if you are with a service preparing this form for a taxpayer, please provide the name of the service and the
contact person.
Contact Person:
Service Name:
Contact Phone Number:
○ ACH Debit Option
If ACH Debit is chosen, the information you provide the Kansas Department of Revenue gives us the authorization to debit your bank for the tax(es)
identified above. Only you can initiate a debit by calling the state’s system and indicating the amount of tax to be paid by electronic funds transfer.
Account Type: (check one)
○
Checking
○
NOTE: PLEASE ENCLOSE A VOIDED CHECK FOR VERIFICATION
Savings
Bank Contact:
Bank Name:
Phone Number: ____________________________
.
Routing # :
Account # :
○ ACH Credit Option
If ACH Credit is chosen, you will be responsible for contacting your bank, indicating the amount you want sent and having the transaction completed
timely for funds to be received by the Kansas Department of Revenue on or before the EFT due date. I hereby request the Kansas Department of
Revenue to grant authority for the above named taxpayer to initiate ACH credit transactions to the State Treasurer’s bank account. I understand these
must be in the NACHA CCD+ format using the TXP convention.
Authorized Signature:
Signature :__________________________________________
Date:
Print Name:
Title:
EF-101 (Rev. 11/03)
American LegalNet, Inc.
www.FormsWorkFlow.com