Free Electronic Funds Transfer Agreement - Tennessee

STATE OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT DIVISION OF EMPLOYMENT SECURITY EMPLOYER ACCOUNTS OPERATIONS 220 FRENCH LANDING DRIVE NASHVILLE, TENNESSEE 37243 FAX 615-741-7214

ELECTRONIC FUNDS TRANSFER AGREEMENT
Employer Name: ____________________________________________________________________________ State UI Account Number: ______________________ Contact Person: ______________________________ E-mail Address: __________________________________ Federal EIN: ____________________________ Telephone Number: ______________________ Fax Number: ___________________________

This is an agreement between the Tennessee Department of Labor and Workforce Development (hereinafter "TDLWD") and _______________________________________________________ (hereinafter "the Employer"), entered into this on this the ___________ day of ___________________, ________ pursuant to the provisions of TCA §50-7-404, Rule 0560-2-1 et. seq. TDLWD and the Employer agree as follows:
1. The TDLWD authorizes the Employer to transmit electronically using the Automated Clearing House (ACH), unemployment insurance premiums (hereinafter "Funds"), due quarterly to the Department by the Employer. The premium due dates will remain the same with regard to interest. TDLWD must receive the funds by the due date or appropriate interest will be assessed. It is the responsibility of the Employer to transmit funds so as to be received by TDLWD's bank by the due date. This Agreement will be effective beginning _________________ quarter/year.

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Employer or Agent Signature _________________________________ Employer or Agent Name Printed _____________________________ Title _____________________________________ Date _________________

Employer or Agent Telephone Number ___________________ TDLWD Official Signature ___________________________ Title _______________________________ Date _________________

LB-0963 (Rev. 04-08)