Free Authorization Agreement for EFT - California


File Size: 48.5 kB
Pages: 2
File Format: PDF
State: California
Category: Tax Forms
Author: BOE Property and Special Taxes Dept.
Word Count: 767 Words, 4,658 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.boe.ca.gov/pdf/boe555st.pdf

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Preview Authorization Agreement for EFT
BOE-555-ST (FRONT) REV. 6 (5-09)

STATE OF CALIFORNIA

AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (EFT)
Please check appropriate boxes:

BOARD OF EQUALIZATION New EFT account Change EFT reporting method Change bank account on

(date)

Change contact name or phone number See reverse for instructions on completing this authorization agreement. (Type or print in ink) SECTION I
TAXPAYER NAME BOE ACCOUNT NUMBER

DBA (Doing Business As)

BUSINESS PHONE NUMBER

(
CONTACT PERSON

) )

CONTACT PHONE NUMBER

( Complete Section II or III below (not both): SECTION II ACH Debit

The Board of Equalization (BOE) is hereby authorized to initiate debit entries to the bank account identified below and the bank is authorized to debit such account. This 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 BOE and I mutually agree to terminate my voluntary participation in the EFT program.
BANK NAME

BANK ACCOUNT NUMBER (not to exceed 17 digits)

Type of Account
Checking Savings
TITLE OF SIGNER DATE

ROUTING NUMBER
SIGNATURE OF TAXPAYER OR AUTHORIZED REPRESENTATIVE

PRINT NAME OF SIGNER AND CAPACITY IN WHICH SIGNED

IMPORTANT:

If you have selected the ACH Debit option, you must attach a voided check for the account to be debited. Your voided check will verify bank account and routing numbers. If you are unable to provide a voided check, a bank specification sheet may be used instead of the voided check.

SECTION III ACH Credit The BOE is hereby requested to grant authority for the above-named taxpayer to initiate ACH credit transactions to the BOE's bank account. These payments must be in the NACHA CCD+ format using the Tax Payment Convention (TXP) and may only be initiated for EFT tax payments to the BOE provided for by statute.
SIGNATURE OF TAXPAYER OR AUTHORIZED REPRESENTATIVE TITLE OF SIGNER DATE

PRINT NAME OF SIGNER AND CAPACITY IN WHICH SIGNED

Return this form to the division that administers the program for the above account: Excise Taxes Division PO Box 942879 Sacramento, CA 94279-0056 For EFT assistance, call 916-327-4208 Environmental Fees Division PO Box 942879 Sacramento, CA 94279-0057 For EFT assistance, call 916-323-9555

Fuel Taxes Division PO Box 942879 Sacramento, CA 94279-0030 For EFT assistance, call 916-322-9669 Make a copy for your records.

CLEAR

PRINT

BOE-555-ST (BACK) REV. 6 (5-09)

Instructions for Completing the EFT Authorization Agreement Form
General
Please type or print clearly and return this form to the BOE promptly. Be sure to make a copy for your records.

Section I
Complete all blocks in this section. Your BOE account number is required, for example (044-123456).

Sections II and III
Complete one of these sections, not both. Complete Section II if you select ACH Debit, or Section III if you select ACH Credit. After making your decision, please check the appropriate box and complete every block of information for the method selected. If the ACH Debit method is chosen, a voided check must be attached to this completed form. Your voided check will verify bank account and routing numbers. The example of a voided check, shown below, indicates where to locate the routing number for your bank and your bank account number. Remember to mark the word "void" across the face of the check that you return with the authorization agreement.

Important Information
1. EFT Start Date for New Accounts You will be notified in writing if your agreement is approved. Your confirmation letter will indicate when you must start making EFT payments. DO NOT attempt to pay by EFT before your approved start date. 2. Withdrawal Information Once you are registered, you cannot withdraw from the EFT program unless your average monthly tax, over a 12-month period, is less than $20,000. If you qualify and wish to withdraw, you must make your request in writing. You must continue to make payments by EFT until the BOE notifies you in writing that your request has been approved and indicates the ending date for making EFT payments. 3. Changing Your Payment Method (ACH Debit vs. ACH Credit) If you are submitting an authorization agreement form to change from ACH Debit to ACH Credit, or vice versa, you must continue to use your current reporting method until you are notified in writing by the BOE that your request has been approved. A confirmation letter will be mailed to you once your method of payment has been changed. 4. New Bank Account or Routing Number If you are submitting an authorization agreement form to change your bank account or routing number, you will not receive a confirmation letter.