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