Form EFT-100D "ACH Debit Payment Method Authorization Agreement" - North Carolina

What Is Form EFT-100D?

This is a legal form that was released by the North Carolina Department of Revenue - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2018;
  • The latest edition provided by the North Carolina Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form EFT-100D by clicking the link below or browse more documents and templates provided by the North Carolina Department of Revenue.

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Download Form EFT-100D "ACH Debit Payment Method Authorization Agreement" - North Carolina

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4
EFT-100D
PRINT
CLEAR
ACH Debit Payment Method Authorization Agreement
Web-Fill
6-18
Business Name
(First 30 Characters) (USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS)
Federal Employer ID Number
Address
Office Use Only
City
State
Zip Code (First 5 digits)
Name of Contact Person
Contact Phone Number
Social Security Number
Title of Contact Person
Contact Fax Number
Contact Business Name (If different than above)
Fill in applicable circle:
Initial registration - mandatory participant
Address (If different than above)
Initial registration - voluntary participant
Change of Information
State
Zip Code (First 5 digits)
City
(Effective Date: __________________ )
Part 1. Select ACH Debit payment method and tax type (Fill in applicable circle)
Tax type available for these methods:
(Select tax type by filling in applicable circle):
Enter your Account ID for the tax type selected
Insurance
Touchtone
Voice
0 0
Premium
Batch (must only be used to transmit 10 or more payments at a time). Note average number of payments to be transmitted
per transmission ______________________ .
Tax types available for this method:
(Select tax type by filling in applicable circle):
Combined General Rate Sales and Use
(Utility, Liquor, Gas, and Other)
Enter your Account ID/NCDOR ID for the tax type selected
Sales and Use
Alcoholic Beverage
0 0
Tobacco Products
Withholding
(Federal Employer ID is required):
Enter your Motor Fuels Account ID/NCDOR ID
Corporate Estimated
Insurance Premium
Motor Fuels
Part 2. Enter Banking Information
1.
Financial Institution Name
Checking
Savings
2.
Account type
(Fill in applicable circle):
3.
Transit or Routing Number
4.
Bank Account Number
Part 3. Authorized Signatures
I authorize the North Carolina Department of Revenue to present debit entries for the
I certify that the individual named above as the Contact Person (if not employed by
bank account and the financial institution named above. Debit transactions will be
my business) is authorized to act on my behalf in regards to ACH Debit transactions
presented only upon my express authorization and initiation and will pertain only to
for the tax type indicated.
ACH payments that are initiated for the payment of North Carolina taxes.
Authorized Signature
Taxpayer Signature
Title
Date
Title
Date
MAIL TO: Electronic Payments Unit, North Carolina Department of Revenue, P.O. Box 25000, Raleigh, North Carolina 27640-0001 or FAX TO: 919-733-3149
4
EFT-100D
PRINT
CLEAR
ACH Debit Payment Method Authorization Agreement
Web-Fill
6-18
Business Name
(First 30 Characters) (USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS)
Federal Employer ID Number
Address
Office Use Only
City
State
Zip Code (First 5 digits)
Name of Contact Person
Contact Phone Number
Social Security Number
Title of Contact Person
Contact Fax Number
Contact Business Name (If different than above)
Fill in applicable circle:
Initial registration - mandatory participant
Address (If different than above)
Initial registration - voluntary participant
Change of Information
State
Zip Code (First 5 digits)
City
(Effective Date: __________________ )
Part 1. Select ACH Debit payment method and tax type (Fill in applicable circle)
Tax type available for these methods:
(Select tax type by filling in applicable circle):
Enter your Account ID for the tax type selected
Insurance
Touchtone
Voice
0 0
Premium
Batch (must only be used to transmit 10 or more payments at a time). Note average number of payments to be transmitted
per transmission ______________________ .
Tax types available for this method:
(Select tax type by filling in applicable circle):
Combined General Rate Sales and Use
(Utility, Liquor, Gas, and Other)
Enter your Account ID/NCDOR ID for the tax type selected
Sales and Use
Alcoholic Beverage
0 0
Tobacco Products
Withholding
(Federal Employer ID is required):
Enter your Motor Fuels Account ID/NCDOR ID
Corporate Estimated
Insurance Premium
Motor Fuels
Part 2. Enter Banking Information
1.
Financial Institution Name
Checking
Savings
2.
Account type
(Fill in applicable circle):
3.
Transit or Routing Number
4.
Bank Account Number
Part 3. Authorized Signatures
I authorize the North Carolina Department of Revenue to present debit entries for the
I certify that the individual named above as the Contact Person (if not employed by
bank account and the financial institution named above. Debit transactions will be
my business) is authorized to act on my behalf in regards to ACH Debit transactions
presented only upon my express authorization and initiation and will pertain only to
for the tax type indicated.
ACH payments that are initiated for the payment of North Carolina taxes.
Authorized Signature
Taxpayer Signature
Title
Date
Title
Date
MAIL TO: Electronic Payments Unit, North Carolina Department of Revenue, P.O. Box 25000, Raleigh, North Carolina 27640-0001 or FAX TO: 919-733-3149
ACH Debit Payment Method Authorization Agreement
Page 2
EFT-100D
Instructions
Web-Fill
6-18
Taxpayer Information
Business Name and Address
Enter the business name and address of the taxpayer.
Name and Address of Contact Person
This is the individual the Department will contact should there be any question about an EFT tax payment and to whom all correspondence
about the EFT Program will be directed. If this person is not employed by the taxpayer, then the Contact Business Name and Address
must be noted (i.e.: XYZ Payroll Service).
Federal Employer ID Number/SSN number
If the business is a corporation, provide the Federal Employer ID Number. If the business is a sole proprietorship, provide the owner’s
Social Security Number.
Mandatory or Voluntary Participant
As a mandatory participant, you must participate in the Program until further notified.
Change of Information/Bank Change
If any information has changed since previously registering, such as the banking information or contact person, please complete a
new authorization agreement with the updated information. Indicate the date the changes should take effect. Normally, bank changes
require 2-3 business days to be processed before a payment can be made.
Account ID Number
The department has replaced some Tax Account ID numbers with a NCDOR ID number. If you have received a NCDOR ID please begin
using it if applicable.
Taxpayers remitting Corporate Estimated taxes or Insurance Premium Tax will enter the nine digit Federal Employer ID Number after
the 2 pre-filled zeros. For Motor Fuels Tax accounts, taxpayers will enter the eleven digit Account ID Number. For all other taxes, enter
the nine digit Account ID/NCDOR ID Number after the 2 pre-filled zeros.
Tax Type
Fill in the circle for the appropriate tax type. If required or requesting to remit electronically for more than one tax type, you must complete
a separate ACH Debit Payment Method Authorization Agreement for each tax type.
General Instructions
Part 1. Select ACH Debit payment method
Notice the different tax types available for each payment method. Select one method for initiating your payments and indicate the tax
type.
For the ACH Debit Touchtone and Voice payment methods, notice that Insurance Premium ONLY is available for these payment
methods. Taxpayers registering for Touchtone and Voice payment methods will receive security information that enable them to access
the Department’s Touchtone and Voice Debit systems.
Batch is an online payment method that is designed for tax service providers and companies that transmit a batch of 10 or more payments
at a time (internet connection required). Enter the average number of payments to be transmitted at a time. If approved for this payment
method, security information will be sent that will enable the batch of payments to be transmitted online.
Part 2. Entering Bank Information
(1) Financial Institution Name - Enter the name of the Financial Institution to which ACH Debit transactions are presented.
(2) Account Type - Indicate whether the account to be debited is a checking or a savings account.
(3) Transit or Routing Number - Obtain the nine digit Transit or Routing Number for ACH transactions from your financial institution.
(4) Bank Account Number - Enter the bank account number to be debited.
Part 3. Authorized Signatures
The taxpayer and/or the individual authorized to act on behalf of the taxpayer regarding ACH tax payments must sign this Authorization
Agreement. The 1st signature line is for authorization of the ACH Debit transactions. The 2nd signature line is for the taxpayer to certify
that the listed Contact Person (if not employed by the taxpayer) is authorized to act on behalf of the taxpayer in regards to ACH Debit
transactions for the tax type indicated.
Other Payment Methods
For your convenience, other electronic payment methods are available through our website at www.ncdor.gov. Bank Draft (ACH Debit),
Debit or Credit Card (Visa or MasterCard) may also be used to satisfy mandatory electronic payment requirements.
Taxpayers that wish to remit Streamlined Sales Tax by the ACH Debit payment method, may do so using the SSTP XML Payment
Schema when submitting the Streamlined Simplified Electronic Return (SER) or separately. Both require the use of web services to
submit XML Schema. Additional information about the Streamlined XML Schemas can be found on the website for the Streamlined
Sales Tax Governing Board, Inc. at http://www.streamlinedsalestax.org by clicking on the SST Technology link.
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