STATE OF RHODE ISLAND 
                          DIVISION OF TAXATION 
                          ONE CAPITOL HILL 
                          PROVIDENCE, RI  02908 
                          (401) 222-6282 – phone 
                           (401) 222-6288 – fax    
                           
              ELECTRONIC FUNDS TRANSFER - CHANGE IN BANK INFORMATION  
                          (ACH DEBIT FILERS ONLY) 
 
NAME OF COMPANY:  _________________________________________________________________ 
 
RHODE ISLAND ID #:   ___  ___  ___  ___  ___  ___  ___  ___  ___  ___  ___ 
 
OLD BANK INFORMATION: 
 
             BANK NAME:  _________________________________________________________________ 
 
             BANK TRANSIT/ROUTING NUMBER:   ___   ___  ___  ___  ___  ___  ___  ___  ___  
             (9 DIGITS) 
              
             BANK ACCOUNT NUMBER:  ____________________________________________________ 
              
NEW BANK INFORMATION: 
 
             BANK NAME:  ________________________________________________________________ 
 
             BANK TRANSIT/ROUTING NUMBER:  ___  ___  ___  ___  ___  ___  ___  ___  ___  
             (9 DIGITS)   
              
             BANK ACCOUNT NUMBER:  ___________________________________________________ 
              
EFFECTIVE DATE OF CHANGE:  ____________________________ 
 
PERSON COMPLETING THIS FORM _________________________________________________________ 
         TYPE OR PRINT NAME 
 
                                                        FOR OFFICE USE ONLY: 
            
          Bank Change Completed: 
          
                                                        Date:  _____________________ 
 
                                                        Init: ______________________
              
EFT Bank Change Form 
rev. 04/2000