EFT-BIC                                Indiana Department of Revenue              Date:    __________________
 State Form 50109
 (R3 /6-10)
                                          EFT
                     Bank Information Change - ACH Debit
 This is for bank change only, it does NOT replace the Authorization Agreement Form (EFT-1)

13 digit Indiana TID # :  _______________________________________________________________________  

Company Name:   ___________________________________________________________________________

Tax Types:   ________________________________________________________________________________

New Bank Information

Bank ABA#  :   ______________________________________________________________________________
 (Transit Routing #)                                                  (Nine Digits)

                                        o Checking      o Savings

Bank Account # :   ___________________________________________________________________________

This change must be effective by: _______________________________________________________________

Will the funds for the ACH Debit payments come from a bank outside of the United States?       o No  o Yes 

           Please print for legibility. The following information is for EFT purposes only.

Company Contact Person:  ____________________________________________________________________  

Address:  __________________________________________________________________________________

  __________________________________________________________________________________

Telephone Number: _____________________________________________________      Ext:  ______________

_____________________________________________________________________   _________________
Authorized Signature                                                   Date

Please attach a voided check to verify the new bank information. Note: Deposit slips do not always have the same ABA/Transit Routing 
number as the checking/savings account. 

 EFT Section, Room N248
 Indiana Department of Revenue
 100 N. Senate Ave.
 Indianapolis,  IN  46204-2253
 or FAX to: (317) 232-1851   Attn: EFT Section

We will confirm the requested change(s) in writing or by telephone. If you have any questions, contact the EFT Section at (317) 232-5500.