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                                                                                                                              PRINT      CLEAR
     Web-Fill                       EFT-100C
       6-18                         ACH Credit Payment Method Authorization Agreement
Business Name (First 30 Characters)  (USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS)
                                                                                                             Federal Employer ID Number

Address

                                                                                                                 Office Use Only
City                                                    State                       Zip Code (First 5 digits)
                                                         
Name of Contact Person                                  Contact Phone Number
                                                                                                             Social Security Number
Title of Contact Person                                 Contact Fax Number

Contact Business Name  (If different than above)                                                             Fill in applicable circle:

                                                                                                             Initial registration - mandatory participant
Address  (If different than above)                                                                           Initial registration - voluntary participant
                                                                                                             Change of Information
City                                                    State                       Zip Code (First 5 digits)
                                                                                                             (Effective Date:                                                   )

Part 1.  Tax Type
Fill in applicable circle to select tax type:
                                                                                             Enter your Streamlined Sales Account ID
         Streamlined Sales and Use
                                                                                             0 0 S

                                                                                             Enter your Motor Fuels Account ID/ NCDOR ID 
         Motor Fuels

         Alcoholic Beverage
         Sales and Use                                                                       Enter your Account ID/ NCDOR ID for the tax type selected
         Severance
         Tobacco Products                                                                    0 0
         Combined General Rate Sales and Use (Utility, Liquor, Gas, and Other)
         Withholding

Fill in applicable circle for tax type (Federal Employer ID is required):
         Corporate Estimated                      Insurance Premium

Part 2.  Authorized Signature
I certify that the individual named above as the contact person is authorized to act on behalf of the taxpayer in regards to ACH Credit transactions for the tax type indicated.

Authorized Signature                              Title                                                      Date

                                                  MAIL TO:  Electronic Payments Unit,  
              North Carolina Department of Revenue, P.O. Box 25000, Raleigh, North Carolina 27640-0001
                                                  or FAX TO: 919-733-3149

Page 2          ACH Credit Payment Method Authorization Agreement
EFT-100C 
 Web-Fill                               Instructions
 6-18

Taxpayer Information

Business Name and Address
 Enter the business name and address of the taxpayer.

Name and Address of Contact Person
 This is the individual the Department will contact should there be any question about an EFT tax payment and to whom 
 all correspondence about the  EFT Program will be directed.  If this person is not employed by the taxpayer, then the 
 Contact Business Name and Address must be noted (i.e.: XYZ Payroll Service).

Federal Employer ID Number/SSN number
 If the business is a corporation, provide the Federal Employer ID Number.  If the business is a sole proprietorship, provide 
 the owner’s Social Security Number.

Mandatory or Voluntary Participant
 As a mandatory participant, you must pay electronically until further notified.

Change of Information
 If any information has changed since previously registering, such as the business name, contact person, or Account ID, 
 please complete a new authorization agreement with the updated information.  Indicate the date the changes should 
 take effect.  Normally, changes require 2-3 business days to be processed before becoming effective.

Tax Type
 Fill in the circle for the appropriate tax type.  You must complete a separate ACH Credit Payment Method Authorization 
 Agreement for each tax type.

Account ID Number
 The department has replaced some Tax Account ID numbers with a NCDOR ID number. If you have received a NCDOR 
 ID please begin using it if applicable.

 If your tax type requires an Account ID/NCDOR ID, please enter in the boxes next to the appropriate tax type selection. 
 Streamlined Sales and Use should register and pay using the Streamlined Sales and Use section by entering the 
 Streamline Sales account ID.

General Instructions

ACH Credit Payment Method
 To make payments by ACH Credit, first contact your financial institution to confirm they offer ACH Credit origination 
 services. After registering with the Department for the ACH Credit method (by submitting a completed ACH Credit Payment 
 Method Authorization Agreement), please review the ACH Credit Instructions and Guidelines on our website www.ncdor.
 gov/documents/ach-credit-instructions-and-guidelines.

Authorized Signature
 An individual authorized to act on behalf of the taxpayer in regards to ACH Credit payment transactions must sign this 
 Authorization Agreement.  Generally, this is the person with the authority to sign a tax return.

Other Payment Methods
 For your convenience, other electronic payment methods are available through our website at www.ncdor.gov.  Bank 
 Draft (ACH Debit), Debit or Credit Card (Visa or MasterCard) may also be used to satisfy mandatory electronic payment 
 requirements.

 Taxpayers that wish to remit Streamlined Sales Tax by the ACH Debit payment method, may do so using the SSTP XML 
 Payment Schema when submitting the Streamlined Simplified Electronic Return (SER) or separately.  Both require the 
 use of web services to submit XML Schema.  Additional information about the Streamlined XML Schemas can be found 
 on the website for the Streamlined Sales Tax Governing Board, Inc. at http://www.streamlinedsalestax.org by clicking 
 on the Technology link.