Authorization Agreement Form For Electronic Funds Transfer {EFT-1}

State Form 50110 (R10 / 9-14) EFT-1 Authorization Agreement Form For Electronic Funds Transfer (Must be 13 digits; see special instructions on back.) Indiana Department of Revenue Indiana Taxpayer Identification Number: ___________________ Date: ______________ Business Name: __________________________________________________ Name and Telephone Number of Individual in Your Organization that Revenue May Contact Regarding EFT: Contact Person: __________________________________________________ (Not a bank contact) (Please print) Address: ________________________________________________________ City, State, ZIP Code: _____________________________________________ Telephone Number: _______________________________________________ Please complete a separate form for each tax type selected. o County Innkeepers (CIT) o Corporate Income (COR) o Gasoline Use (GUT) o Special Fuel (SFT) o II Gaming (TTG) Type o Financial Institution (FIT) o Motor Fuel Use (MFT) o Streamlined Sales (SST) o Utility Receipts (URT) o Food and Beverage (FAB) o Sales (RST) o Fee (TIF) Tire o Wireless Prepaid 911 Fee (WPC)o Withholding (WTH) Please choose an EFT method. If you choose ACH Debit, you must also complete the banking information portion of this form and attach a copy of a voided check to verify the banking information. o Credit ACH Do not use this form to register for INtax. Visit www.intax.in.gov. o Debit* (Complete bank information) ACH Bank ABA Number: _____________________ (transit routing number) o Checking Will the funds for the ACH Debit payments come from a bank outside of the United States? If yes, the EFT Section will contact you. _________________________________________ Authorized Signature ___________________ Title or o Savings Your Account Number: ___________________ (With the above bank) oNo oYes ______________ Date *If ACH Debit is chosen, the taxpayer hereby authorizes the Indiana Department of Revenue to present debit entries into the bank account referenced above as required by Indiana law. These debits will pertain only to electronic funds transfer payments that the taxpayer has initiated. This form may be faxed or mailed. Fax: (317) 232-1851 Questions: (317) 232-5500 Indiana Department of Revenue EFT Section, Room N248, MS 103 100 N. Senate Ave. Indianapolis, IN 46204-2253 American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing Authorization Agreement Form Indiana TID Number - Enter your 13-digit Indiana TID number. Your Indiana TID number is not your federal ID number, with the exception of corporate income, financial institution, and utility receipts taxes. See below. Corporate income, financial institution, or utility receipts tax types must use their nine-digit federal ID number plus four additional digits at the end as assigned by the department. If you do not know the last four digits, contact the EFT Section at (317) 232-5500. Streamlined Sales Tax EFT ID Numbers - The EFT Taxpayer Identification for Streamlined Sales Tax is the Streamlined Sales account number assigned during the Streamlined Sales registration. The Streamlined Sales identification number should be aligned to the left of the field; therefore, the number would be S99999999. The certified service provider's (CSP's) identification number can be used in the future when Indiana accepts the bulk payment from certified service providers. The identification number would be formatted as CSP999999. Tax Type - Please complete and submit a separate EFT-1 form for each tax type for which you are registering for EFT. Bank Information - This section needs to be completed only by those taxpayers selecting the ACH Debit method. You must indicate whether the account is checking or savings. The ABA/Transit routing number must be nine digits. Note: You cannot have multiple accounts for a single tax payment. Please verify the accuracy of the bank information entered. Taxpayer Contact - Enter the name and complete address of the person who should be contacted with information concerning EFT tax payments or regarding problems with EFT payments. Do not enter the name of someone at your bank. The department must have a taxpayer contact. Tax service providers may enter their contact information if they have power of attorney to represent the taxpayer. A contact telephone number must also be provided. Bank Outside the U.S.? - To comply with new International ACH Transaction (IAT) rules from NACHA, the department must provide additional information with ACH transactions going into or coming from a bank outside the United States. If you answered yes to the question, the department will contact you to obtain additional information. American LegalNet, Inc. www.FormsWorkFlow.com