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EFT-100D                                                                                                                                                                 6
Web-Fill                            ACH Debit Payment Method Authorization Agreement                                                               PRINT                 CLEAR
12-15                                             North Carolina Department of Revenue
Business Name (First 30 Characters)  (USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS)
                                                                                                                         Federal Employer ID Number 
Address                                                                                                                    

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

Part 1.  Select ACH Debit payment method and tax type (Fill in applicable circle)
                                                   Tax type available for these methods:  (Select tax type by filling in applicable circle):
                                                                                                                 Enter your Account ID for the tax type selected
      Touchtone                     Voice                                             Insurance
                                                                                      Premium                    0 0       

      Batch (must only be used to transmit 10 or more payments at a time).  Note average number of payments to be transmitted 
      per transmission  ______________________    .
         Tax types available for this method:  (Select tax type by filling in applicable circle):
         Combined General Rate Sales and Use Tax Return (Utility, Liquor, Gas, and Other)                        Enter your Account ID/NCDOR ID for the tax type selected
         Machinery and Equipment                  Tobacco Products                          Withholding
                                                                                                                           
         Sales and Use                            Alcoholic Beverage                                             0 0
         (Federal Employer ID is required):                                                                      Enter your Motor Fuels Account ID/NCDOR ID

         Corporate Estimated                      Insurance Premium                    Motor Fuels                        

Part 2.  Enter Banking Information
1.  Financial Institution Name

2.  Account type  (Fill in applicable circle):    Checking                                      Savings
3.  Transit or Routing Number                     4.  Bank Account Number
                                                    
Part 3.  Authorized Signatures
I authorize the North Carolina Department of Revenue to present debit entries for the I certify that the individual named above as the Contact Person (if not employed by 
bank account and the financial institution named above.  Debit transactions will be   my business) is authorized to act on my behalf in regards to ACH Debit transactions 
presented only upon my express authorization and initiation and will pertain only to  for the tax type indicated.
ACH payments that are initiated for the payment of North Carolina taxes.

Authorized Signature                                                                  Taxpayer Signature

Title                                             Date                                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
EFT-100D         ACH Debit Payment Method Authorization Agreement
 Web-Fill                                             Instructions
 12-15

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 participate in the Program until further notified.
  As a voluntary participant, you must participate in the Program for a minimum of twelve months.  Upon completion of the twelve month 
 period, you may withdraw from the Program provided you have notified the Department in writing at least 45 days prior to the first non-
 EFT payment.
Change of Information/Bank Change
  If any information has changed since previously registering, such as the banking information or contact person, please complete a 
 new authorization agreement with the updated information.  Indicate the date the changes should take effect.  Normally, bank changes 
 require 2-3 business days to be processed before a payment can be made.
Account ID Number
  The department has replaced some Tax Account ID numbers with a new NCDOR ID number. If you have received your new NCDOR 
 ID please begin using it if applicable.
  Taxpayers remitting Corporate Estimated taxes or Insurance Premium Tax will enter the nine digit Federal Employer ID Number after 
 the 2 pre-filled zeros. For Motor Fuels Tax accounts, taxpayers will enter the eleven digit Account ID Number. For all other taxes, enter 
 the nine digit Account ID/NCDOR ID Number after the 2 pre-filled zeros.
Tax Type
  Fill in the circle for the appropriate tax type.  If required or requesting to remit electronically for more than one tax type, you must complete 
 a separate ACH Debit Payment Method Authorization Agreement for each tax type.
General Instructions
Part 1. Select ACH Debit payment method
  Notice the different tax types available for each payment method.  Select one method for initiating your payments and indicate the tax 
 type.
  For the ACH Debit Touchtone and Voice payment methods, notice that Insurance Premium ONLY is available for these payment 
 methods.  Taxpayers registering for Touchtone and Voice payment methods will receive security information that enable them to access 
 the Department’s Touchtone and Voice Debit systems.
  Batch is an online payment method that is designed for tax service providers and companies that transmit a batch of 10 or more payments 
 at a time (internet connection required). Enter the average number of payments to be transmitted at a time. If approved for this payment 
 method, security information will be sent that will enable the batch of payments to be transmitted online. 
Part 2.  Entering Bank Information
 (1)  Financial Institution Name - Enter the name of the Financial Institution to which ACH Debit transactions are presented.
  (2)  Account Type - Indicate whether the account to be debited is a checking or a savings account.
  (3)  Transit or Routing Number - Obtain the nine digit Transit or Routing Number for ACH transactions from your financial institution.  
  (4)  Bank Account Number - Enter the bank account number to be debited.
Part 3.  Authorized Signatures
  The taxpayer and/or the individual authorized to act on behalf of the taxpayer regarding ACH tax payments must sign this Authorization 
 Agreement.  The 1st signature line is for authorization of the ACH Debit transactions.  The 2nd signature line is for the taxpayer to certify 
 that the listed Contact Person (if not employed by the taxpayer) is authorized to act on behalf of the taxpayer in regards to ACH Debit 
 transactions for the tax type indicated.
Other Payment Methods
  For your convenience, other electronic payment methods are available through our website at www.dornc.com.  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 SST Technology link.