Authorization Agreement for 

                                                              Electronic Funds Transfer (EFT) of

                                                               LWC Unemployment Tax Payments
                                                                    FOR ACH CREDIT AUTHORIZATION ONLY

New Application        Update                                                                                            

Employer Name or Authorized Agent                                                               *State ID#. Federal ID#.

1ST Contact Person     Telephone                              2nd Contact Person                                        Telephone

Mailing Address for EFT purposes (Street Address, Box number) 

Signature                                                     Title                                                     Date

* When filing for multiple employers, attach listing in the format below or list the
  State ID#, Federal ID#, and DBA Name in the space provided below.

State UI No.       Federal Id No. DBA (doing business as)
123456-7           99-9999999     ABC Company Inc.

Mail/ Fax Agreement To:
Fax(225) 342-5822/Phone(225)342-2955
Louisiana Workforce Commission
Office of Unemployment Insurance Administration
EFT Processing/UI Accounting
P. O. Box 94100
Baton Rouge, LA  70804-9186
 
Last Rev.(12/08)