State of New Jersey DEPARTMENT OF THE TREASURY DIVISION OF REVENUE PO Box 628 TRENTON, NJ 08646-0628 R. David Rousseau Jon S. Corzine State Treasurer Governor In keeping with New Jersey’s "One Stop Shopping" initiative, the Division of Revenue has expanded the EFT Program to include Unemployment, Disability, Workforce Development, and Health Care contributions previously sent to the Department of Labor. While making Employer Withholding payments is still mandatory for some employers; the use of EFT for these payments is voluntary for all employers. As an ACH Debit participant in the EFT Program, you know that the Division can not debit an account without proper authorization. Attached is a modified enrollment form for this payment type for you to complete and return to the Division. This will allow you to begin making these payments in addition to your Employer Withholding payments. If you wish to take advantage of EFT for this payment type, please complete and return the form, with the required attached document(s) to the Division as soon as possible. Please attach the required voided check or other form of bank verification for the indicated account. We will then forward the payment codes and addendum information. If you have any questions you may contact the EFT Unit at (609) 984-9830, fax (609) 292-1777or visit our web site at www.state.nj.us/treasury/revenue. Taxpayer ID #: _______ - _______ -_______ /_______ Type: UI/DI __________________________________________________________________ Taxpayer Name ____________________________ _________________________ __________________________________ ______________________________ __________________________________ ______________________________ Transit/Routing Number Contact Name Signature Bank Account Number Title Telephone # Return to: New Jersey Division of Revenue, EFT Unit, POB 191, Trenton, NJ 08646-0191 New Jersey Is An Equal Opportunity Employer • Printed on Recycled and Recyclable Paper American LegalNet, Inc. www.FormsWorkflow.com