Free DR-600A - Florida

Enrollment and Authorization for e-Services Program

DR-600A N. 11/08

Section 1 ­ Check the Box That Applies
Initial enrollment
Complete all sections

Change in filing/ payment method
Complete sections 2, 4, 5, and 6

Bank change
Complete sections 2, 5, and 6

Contact information change
Complete sections 2, 3, & 6

Section 2 ­ Business Information
Business entity name Type of remittance/fee

FEIN/SSN

License/Permit/Agency number (if different from FEIN/SSN)

Physical address

City/State/ZIP

Telephone number (include area code)

Fax number (include area code)

Check Entity Type: Corporation (check type) Partnership (check type) Limited Liability Company (check type) Sole Proprietorship Business Trust Governmental Agency C Corp General Single Member S Corp Limited Multi-member Joint Venture

Section 3 ­ Contact Information
Electronic Payment Contact Person's Information
Name

Mailing address

City/State/ZIP

Telephone number (include area code)

Fax number (include area code)

E-mail address

Section 4 ­ Fee/Remittance Type Payment Method Selection Locate the remittance or fee type, select the payment method you intend to use, and check the appropriate box. Type of Remittance or Fee
DMS - Florida Retirement System contributions DMS - Division of State Group Insurance premiums (universities) BPR - Tobacco fees BPR - Beverage fees BPR - Pari-mutuel taxes and fees BPR - Pari-mutuel slot receipts and fees BPR - Pari-mutuel card room receipts and fees
*You must supply a letter that states a valid business reason for selecting the ACH-Credit payment method. Valid reasons include your previous use of this method in other business-related activities, or internal controls within your business regarding ACH transfers.

EFT only (ACH Debit)

EFT only (ACH Credit)*

DR-600A N. 11/08 Page 2

Section 5 ­ Banking Information Note: Section 5 is not required for ACH Credit payment method. Bank Name _________________________________________ Bank Account No. ___________________________________ Account Type Business Checking Personal Checking Business Savings Personal Savings ABA Routing/Transit No.

Section 6 ­ Enrollee Authorization and Agreement This is an Agreement between the Florida Department of Revenue, hereinafter "the Department," and the business entity named herein, hereinafter "the Enrollee," entered into according to the provisions of the Florida Statutes and the Florida Administrative Code. By completing this agreement and submitting this enrollment request, the Enrollee applies and is hereby authorized by the Department to make tax and fee payments, and transmit remittances to the Department electronically. This agreement represents the entire understanding of the parties in relation to the electronic transmission of tax and fee payments. The same statute and rule sections that pertain to all manual payments made by the Enrollee also govern a payment made electronically according to this enrollment. I certify that I am authorized to sign on behalf of the business entity identified herein, and that all information provided in this document has been personally reviewed by me and the facts stated in it are true. According to the payment method selected above, I hereby authorize the Department to present debit entries into the bank account referenced above at the depository designated herein (ACH-Debit), or I am authorized to register for the ACH-Credit payment privilege and accept all responsibility for the filing of payments through the ACH-Credit method.
_________________________________________________________________ Signature _________________________________________________________________ Print Name _________________________________________________________________ Second signature (if dual signature account) ______________________________ Title ______________________________ Telephone Number ______________________________ Title _____________________________ Date _____________________________ Date

Complete and mail this form to:
e-Services Unit Florida Department of Revenue PO Box 5885 Tallahassee FL 32314-5885 Fax 850-922-5088

www.myflorida.com/dor

Call for assistance: 800-352-3671