Arizona Department of Revenue  •  EFT Unit                                                 DOR USE ONLY
                 Comptroller’s Office                                                                    Credit
                 1600 West Monroe  •  Phoenix, AZ  85007-2650
                 Fax:  (602) 771-9913
                 www.azdor.gov

       AUTHORIZATION FOR ELECTRONIC FUNDS TRANSFER AND DISCLOSURE AGREEMENT – 
                                                           FOR CREDIT FILERS

                 PartsIandIImustbefilledoutcompletelyandtheformmustbesigned.
                 •  This form is for ACH Credit Filers only.
                 •  If you wish to use the ACH Debit Option, please register at www.AZTaxes.gov.

Part TaxpayerInformation(required)
  1 BUSINESS NAME                                                 7 EFT CONTACT NAME

  2 BUSINESS STREET ADDRESS 1                                     8 EFT CONTACT TITLE

  3 BUSINESS STREET ADDRESS 2                                     9 BUSINESS PHONE NUMBER (with area code)

  4 BUSINESS CITY                5  STATE 6  ZIP CODE             10 EFT CONTACT FAX NUMBER (with area code)

Part II:  ACH Credit Option ONLY
    I hereby request that the Arizona Department of Revenue grant authority for the above-named taxpayer or their agent (Part I) to 
     initiate ACH credit transactions to the Department of Revenue bank account.  It is understood that these transactions must be in 
     the NACHA CCD+ format using the Tax Payment Convention and may be initiated for the tax type(s) specified in Part II.

     11      Estimated Corporate Income Tax  12          Payroll Withholding Tax EIN: 13 Transaction Privilege & Use Tax
      EIN:                                                                                  AZ TPT No:
                                                                                         
PartDisclosure    Agreement
    Check this box only if a third party not named on this form is being designated by the taxpayer indicated in Part I to receive 
     taxpayer confidential information from the Arizona Department of Revenue.  By signing this form, the undersigned authorizes the 
     department to release confidential information relating to Arizona Department of Revenue Authorization Agreement and 
     Disclosure Agreement for Electronic Funds Transfer authorization to:
    
    This Disclosure Agreement automatically revokes all earlier EFT authorization agreements and disclosure agreements on file 
     with the Arizona Department of Revenue.  Check this box if you do not want to revoke a prior EFT authorization agreement and 
     disclosure agreement.  YouMUSTattachacopyofanyprioragreementsyouwanttoremainineffect.

PartIVSignature
This form is not a Power of Attorney and does not grant the contact person(s) any power of representation.  This disclosure 
authorization is to remain in force until rescinded by the undersigned.  By signing this form, I certify that I have the authority to execute 
this authorization form on behalf of the above-mentioned corporation(s), limited liability company(ies), trust(s), partnership(s), and/or 
individual(s).

 Taxpayer’s Authorized Signature                           Title                                            Date

 Payroll / Accounting Service Group’s Authorized Signature Title                                            Date
                                 NOTE:  This form may be duplicated.  Please make a copy for future use.
ADOR 10366 (4/20)
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