VIRGINIA DEPARTMENT OF TAXATION
ELECTRONIC FUNDS TRANSFER AUTHORIZATION AGREEMENT
ALL TAXPAYERS AND PAYROLL SERVICE PROVIDERS, COMPLETE SECTION A.
Legal Name of Business or Organization:
Primary EFT Contact: Phone ( )
A.
P
A
Y
E
R
I
N
F
O
Entity Type – Circle One: Business Taxpayer Payroll Service Provider
Email Address:___________________________________________________
Mailing Address for EFT Information:
Street ___________________________________________________
City State Zip - _________
Note to Payroll Service Providers / Bulk Filers – you do not need to provide the Department with a list of your clients. Simply complete
section A and mail or fax to the Department. We will then provide you with the state’s bank information. Also, if you provide an email
address, the Department will add you to a tax professional mailing group and provide you with timely updates regarding EFT processing
requirements and any form or legislative changes that may impact your clients.
IF CHOOSING THE DEBIT PAYMENT METHOD, COMPLETE THIS SECTION
Tax Type
Account Number (s) Bank Account Number(s)
Check to indicate
Account Type
Bank Routing & Transit
Number(s)
Withholding
(VA Tax Account Number)
(Federal ID Number - FEIN)
1)
2)
Checking Savings