Authorization Agreement For Electronic Funds Transfer
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Authorization Agreement For Electronic Funds Transfer Form. This is a New Jersey form and can be use in Business Registration Secretary Of State.
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Tags: Authorization Agreement For Electronic Funds Transfer, EFT1-D, New Jersey Secretary Of State, Business Registration
STATE OF NEW JERSEY
DIVISION OF REVENUE
ACH DEBIT ENROLLMENT
EFT1-D
AUTHORIZATION AGREEMENT FOR
ELECTRONIC FUNDS TRANSFER (EFT)
Reminder: Once qualified for electronic funds transfer (EFT), remit all payments collected by the Division of Revenue using EFT.
Sign and date this enrollment form and return to: New Jersey Division of Revenue, PO Box 191, EFT Unit, Trenton NJ 08646-0191
Please note: All fields are required.
Taxpayer Name:
Transit/Routing Number
New Jersey Registration Number (12 digits):
Bank Account Number
Checking / Savings
Payment / Tax / Fee Type
Federal Identification Number (9 digits):
Contact Name and Address
Contact Telephone Number
The New Jersey Division of Revenue is hereby authorized to debit entries to the bank account(s) identified above and the bank is authorized to debit such account(s). The authority
is to remain in full force until EFT payments are no longer required by statute or, if I am a voluntary participant, until the New Jersey Division of Revenue and I mutually agree to
terminate my participation in the EFT program.
Signature:
Title:
Date:
d
(09/04)
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