Authorization Agreement For Electronic Funds Transfer {EFT1-C}

STATE OF NEW JERSEY DIVISION OF REVENUE ACH CREDIT ENROLLMENT EFT1-C 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: NJ Registration Number (12 digits): Federal Identification Number (9 digits): PAYMENT / TAX / FEE TYPE CONTACT NAME, ADDRESS and EMAIL ADDRESS CONTACT TELEPHONE NUMBER The New Jersey Division of Revenue is hereby requested to grant authority for the above-named taxpayer to initiate ACH Credit transactions to the State of New Jersey, Division of Revenue's bank account. These payments must be in the NACHA CCD+ format using the Tax Payment Convention (TXP) and may be initiated for the EFT payments to the New Jersey Division of Revenue provided by statute. 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: (3/10) American LegalNet, Inc. www.FormsWorkFlow.com