Department Use Only 

                                ELECTRONIC FUNDS TRANSFER (EFT) 
           STATE DATA COLLECTOR PROGRAM -VENDOR (THIRD PARTY) 
                                NEW ENROLLMENT REQUEST FORM 

(See reverse for instructions.) 

SECTION I: Employer information must be completed. 

Business Name                                                Employer Account Number 

Business Mailing Address (Number, Street, or Box Number)     Business Phone Number 

Business Mailing Address (City, State, ZIP Code) 

EFT Contact Person                                           EFT Contact Phone 

SECTION II: Enrollment Authorization 

I hereby authorize designated financial agents of the Employment Development Department (EDD) to 
enroll the Employer Account Number, indicated above, in the state data collector program. 

Important: A form without the signature will be returned unprocessed. 
Signature                                          Title 

Print Name                                         Date               Phone Number 

Fax the completed form to 916-654-7441, or 
Mail to:  e-Pay Unit, MIC 15A 
Employment Development Department 
PO Box 826880 
Sacramento, CA 94280-0001 

If you have questions regarding this form, please call the e-Pay Unit at 916-654-9130. 

DE 26 Rev. 10 (6-16) (INTERNET)                  Page 1 of 2                                               CU 

    Instructions for Completing the       Electronic Funds Transfer (EFT)     State Data  Collector 
                       Program   - Vendor (Third Party) New Enrollment Request     Form 
                                       (www.govone.com/PAYCAL)  
  
 GENERAL  
 Please type or print clearly. Return the New Enrollment Request      form to the  EDD by mail or fax. 
  
 This authorization form is for employers who are not currently enrolled in the state data collector 
 program - vendor (third party) website. 
  
 The employer accepts all responsibility      for managing access to their profile on the state data 
 collector system. 
  
 Once  enrolled, you will receive a confirmation letter with instructions on how to create your profile 
 and add a bank account  to be used for debiting. You will also be able to update your bank account  
 information directly from the state data collector website. 
  
 SECTION I  
 Complete all information in this section.  
  
 Business Name -Enter     the business name. 
  
 Business Mailing Address -Enter          the business mailing address. 
  
 Employer Account Number   -       The EDD employer payroll tax account number is required. 
 Enter the eight-digit employer payroll tax account number assigned by the EDD, not your 
 Federal Employer Identification Number. 
 
 Business Phone Number -Enter           the business phone number. 
 
 EFT Contact Person -Enter         the name of the person who can be contacted regarding this 
 enrollment or tax payment inquiries.  
 
 EFT Contact Phone Number -Enter          the phone number for the contact person. 
 
 SECTION II 
 Preparer or responsible individual, complete all information in this  section.  
 
 Fax the completed form to 916-654-7441,   or 
 
 Mail to:   e-Pay Unit, MIC 15A  
           Employment Development Department  
           PO Box 826880 
           Sacramento, CA 94280-0001  
 
 If you have questions regarding this     form, please call the e-Pay Unit at 916-654-9130. 

DE  26 Rev. 10 (6-16)  (INTERNET)                  Page 2 of 2                                          CU