Form Ri Eft 1 – Fill Out and Use This PDF

FORM RI-EFT-1			STATE OF RHODE ISLAND
			DEPARTMENT OF REVENUE
			DIVISION OF TAXATION
			ONE CAPITOL HILL
			PROVIDENCE, RI 02908-5800
	AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFERS
FEDERAL IDENTIFICATION NUMBER:			___ ___ ___ ___ ___ ___ ___ ___ ___
TYPE OF TAX:
[		] WITHHOLDING		[	] SALES/USE
[		] CORPORATION		[	] INSURANCE PREMIUMS
[		] GASOLINE/MOTOR FUEL		[	] TANGIBLE PERSONAL PROPERTY
[		] BANK DEPOSITS		[	] PUBLIC SERVICE GROSS EARNINGS
[		] BANK EXCISE		[	] CIGARETTE STAMP
[		] CONSUMER USE TAX		[	] LITTER-BEV CONTAINER
[		] HOTEL TAX		[	] HEALTHCARE TAX
[		] LOCAL MEALS & BEV TAX		[	] ALCOHOLIC BEV IMPORT SERVICE FEE
[		] UNIFORM OIL RESPONSE & PREV		[	] WARWICK PARKING TAX
[		] PASS-THROUGH		[	] COMPOSITE INCOME TAX
[		] TOBACCO PRODUCTS		[	] E-911	$0.26 WIRELESS SURCHARGE
[		] E-911 $1.00 WIRELESS SURCHARGE		[	] E-911	$1.00 WIRELINE SURCHARGE
[		] TEL-COM EDUCATION ACCESS FUND		[	] OUTPATIENT HEALTHCARE FACILITY SURCHARGE
[		] HEALTHCARE IMAGING SERVICES SUR

Sections A & B below must be completed by all taxpayers

A.COMPANY DATA

COMPANY NAME:____________________________________________________________________________________

D/B/A:________________________________________________________________________________________________

ADDRESS:____________________________________________________________________________________________

CITY:___________________________________ STATE:__________________ ZIP CODE:___________________

TELEPHONE NO.: _(________)_____________________ FAX NO.: _(________)______________________

B.CONTACT PERSON(S):

Primary EFT contact person:

NAME:___________________________________________TITLE:______________________________________________

ADDRESS:____________________________________________________________________________________________

CITY:___________________________________	STATE:__________________	ZIP CODE:___________________
TELEPHONE NO.: _(____ _)__________________	EXT. _____________ FAX NO.: _(________)_________________

E-MAIL ADDRESS:________________________________________________

Secondary EFT contact person:

NAME:___________________________________________TITLE:______________________________________________

TELEPHONE NO.: _(____ _)__________________ EXT. _____________ FAX NO.: _(________)_________________

E-MAIL ADDRESS:________________________________________________

REVISED 10/17/2007

FORM RI-EFT-1

CHOOSE ONLY ONE OF THE TWO PAYMENT OPTIONS BELOW

C.ACH DEBIT OPTION

This section is to be completed only if you choose the ACH DEBIT OPTION.

TWO DEBIT OPTIONS AVAILABLE:

1.INTERNET FILING: Simply log onto https://www.ri.gov/taxation/business/index.php and click on the first time

user link. This is the only EFT registration process that you need to do.

Do not complete or remit this form to the RI Division of Taxation EFT Section.

2.TELEPHONE: Complete Section C and remit authorization agreement to the RI Division of Taxation EFT Section.

If ACH Debit is chosen, you authorize the Rhode Island Division of Taxation to present debit entries to your bank for the tax identified on the front. Only you can initiate a debit by calling the state's service bureau and indicating the amount of tax to be paid by electronic funds transfer.

Enclose a copy of a voided check or have an AUTHORIZED REPRESENTATIVE of your bank complete and sign this section of the form.

BANK NAME:_________________________________________________________________________________________

ADDRESS:____________________________________________________________________________________________

CITY:___________________________________ STATE:__________________					ZIP CODE:___________________
BANK ACCOUNT #:______________________________ BANK ROUTING/TRANSIT					NUMBER _______________________
[ ]	CHECKING	[ ]	SAVINGS
____________________________________________________				____________________________________
	Printed Name of Bank Representative				Telephone No.
____________________________________________________				____________________________________
	Signature of Bank Representative				Date

D. ACH CREDIT OPTION

This section is to be completed only if you choose the ACH CREDIT OPTION.

All ACH CREDIT must be initiated in the required CCD+ and TXP format. Any payments not received in that format may be considered late.

Example:

Generic TXP addendum record CCD format

FIELD #:	FIELD NAME: DATA ELEMENT TYPE:		FIELD LENGTH:	COMMENTS:
	Segment Id			TXP
	Field Separator			*
TXP01	Taxpayer Id	AN	11	12345678900
	Field Separator			*
TXP02	Tax Type Code	ID	5	55555
	Field Separator			*
TXP03	Tax period End Date	DT	6	YYMMDD
	Field Separator			*
TXP04	Amount Type	ID	1	T(Tax)
	Field Separator			*
TXP05	Amount Paid	N2	1/10	$$$$$$$$cc
	Record Terminator			/

This form must be completed and mailed to: Electronic Funds Transfer Program

Rhode Island Division of Taxation

One Capitol Hill

Providence, RI 02908-5800

Phone (401) 574-8TAX

FAX (401) 574-8913

REVISED 10/17/2007