STATE OF RHODE ISLAND
STATE OF RHODE ISLAND
DEPARTMENT OF ADMINISTRATION
DIVISION OF TAXATION
EMPLOYER TAX SECTION
ONE CAPITOL HILL - STE. 36
PROVIDENCE, RI 02908-5829
(401) 222-3682
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFERS
RI EMPLOYER REGISTRATION NUMBER __ __ __ __ __ __ __ __ __ __
TYPE OF TAX: EMPLOYMENT SECURITY
TEMPORARY DISABILITY INSURANCE
JOB DEVELOPMENT FUND
FIRST QUARTER THAT FUNDS WILL BE TRANSFERRED ELECTRONICALLY:
Sections A, B and C below and on back must be completed by all taxpayers
A. COMPANY DATA
COMPANY NAME: _______________________________________________________________________________
D/B/A/: _________________________________________________________________________________________
ADDRESS: ______________________________________________________________________________________
CITY: ___________________________________STATE: ____________________ZIP CODE: ___________________
B. CONTACT PERSON (S):
Primary EFT contact person:
NAME: __________________________________________ TITLE: ________________________________________
ADDRESS: _____________________________________________________________________________________
CITY: ___________________________________ STATE: ____________________ZIP CODE: _________________
TELEPHONE NUMBER: (_____)______________________ EXT: __________________
Secondary EFT contact person:
NAME: __________________________________________ TITLE: _______________________________________
ADDRESS: ____________________________________________________________________________________
CITY: ___________________________________ STATE: ____________________ZIP CODE: ________________
TELEPHONE NUMBER: (_____)______________________ EXT: ___________________
______________________________________________________
Signature of Owner, Partner or Officer of Corporation
Date
C. ACH CREDIT METHOD
The ACH CREDIT is the only EFT method currently available.
If you are already remitting using the ACH CREDIT method with the Federal Government or for other state taxes, just return this form. If this is the first time that you will be using the ACH CREDIT method, you must have an AUTHORIZED REPRESENTATIVE of your bank complete and sign this section confirming that you and your bank are capable of initiating ACH CREDITS in the required CCD+ and TXP format.
BANK NAME: ____________________________________________________________
ADDRESS: ______________________________________________________________
CITY: ____________________________STATE____________ZIP CODE: __________
___________________________________
Printed Name of Bank Representative
Telephone Number
___________________________________
Signature of Bank Representative
Date
This form must be completed and mailed to:
Electronic Funds Transfer Program
Rhode Island Division of Taxation
Employer Tax Section
One Capitol Hill - STE. 36
Providence, RI 02908-5829
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