OHIO TREASURER OF STATE 
                                                        Robert Sprague 
                             Electronic Funds Transfer Authorization Agreement  

  By using this Service, you agree to the Terms and Conditions and that your payment and use of the Service 
  complies with all federal, state, and local laws, rules, regulations, and ordinances applicable to you, TOS, or any 
                                                        third-party provider used by this Service.  
                                                        Updated Terms and Conditions: 
  
              PLEASE COMPLETE ONE FORM PER FEDERAL ID NUMBER FOR TAX TYPES LISTED BELOW 
PART I TAXPAYER INFORMATION                             Federal ID Number 
 
Taxpayer Name                                           Contact Person 

Mailing Address                                         Telephone Number 

City, State, Zip Code                                   Fax Number 

Email Address 

Part II Tax Type                                      □ New EFT Account                                          □ Modify EFT Account 
                      SELECT THE TAX TYPE FOR THE FEDERAL ID NUMBER LISTED ABOVE 
                                                        □ MUNI NET PROFIT 

                                                        □ PASS THROUGH ENTITY   1140 

                                                        □ PASS THROUGH ENTITY   4708 

                                                        □ PASS THROUGH ENTITY   1041 

PART III ACH CREDIT OPTION (Taxpayer initiates payment through their bank) 
I hereby request the State of Ohio Treasurer’s Office to grant authority for the above named taxpayer to initiate ACH 
Credit Transactions to the State Treasurer’s Office bank account.  It is understood that these transactions must be in the 
NACHA CCD+ format using the TXP Payment Convention and may only be initiated for the tax type specified above. 

Authorized Signature                                                                                                                        Date 

 Ohio Treasurer of State                                                                              Frequently asked questions or Forms:      
 Attn: Electronic Payments Unit                                                                 WWW.EFT.TOS.OHIO.GOV 
 30 E. Broad Street 9th Floor                                                                       EPU Help Line 877-338-6446 
 Columbus, OH 43215-3461                                                                         Fax 614-752-5377 
  
 Revised 6/21/2019