American LegalNet, Inc. www.FormsWorkFlow.com Taxpayer Name: Tax ID #: - - Contact Name: Phone: () Fax #: () Street Address: City: State: Zip: Account Type: Select one Checking Savings Please provide the updated transit/routing and bank account numbers along with the tax(es), fee(s) and/or payment(s) you wish to address by using the updated account. New Transit/Routing #: New Bank Acct. #: Tax/Fee/Payment 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: