Main Navigation
Form BOE-555-ST Fillable Authorization Agreement for Electronic Funds Transfer (EFT)
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)(2nd digit) (3rd digit) (4th digit) (5th digit) (6th digit) (7th digit) (8th digit) (9th digit) (BANK ACCOUNT NUMBER (not to exceed 17 digits)) (BANK NAME) (BOE ACCOUNT NUMBER) (BUSINESS PHONE NUMBER (AREA CODE) ) (BUSINESS PHONE NUMBER) (CLEAR) CLEAR (CONTACT PERSON) (CONTACT PHONE NUMBER ( AREA CODE)) (CONTACT PHONE NUMBER ) (date) (DATE) (DBA (Doing Business As)) (PRINT NAME OF SIGNER AND CAPACITY IN WHICH SIGNED) (PRINT) PRINT (ROUTING NUMBER 1st digit) (Savings) Unchecked (SIGNATURE OF TAXPAYER OR AUTHORIZED REPRESENTATIVE TITLE OF SIGNER) (TAXPAYER NAME) (Type or print in ink) 1 EFT Start Date for New Accounts 2 Withdrawal Information 3 Changing Your Payment Method (ACH Debit vs ACH Credit) 4 New Bank Account or Routing Number A confirmation letter will be mailed to you once your method of payment has been changed account and routing numbers ACH Credit ACH Debit appropriate box and complete every block of information for the method selected AUTHORIZATION AGREEMENT FORBOARD OF EQUALIZATIONELECTRONIC FUNDS TRANSFER (EFT) BANK ACCOUNT NUMBER(not to exceed17 digits) BANK NAME BOE 555 ST (BACK) REV 7 (10 10) BOE 555 ST (FRONT) REV 7 (10 10)STATE OF CALIFORNIA BOE ACCOUNT NUMBER Change contact name or phone number Checking Complete all blocks in this section Your BOE account number is required for example (044 123456) Complete one of these sections not both Complete Section II if you select ACH Debit or Section III if you select ACH Credit After making your decision please check the Complete Section II or III below (not both): confirmation letter CONTACT PERSON CONTACT PHONE NUMBER continue to use your current reporting method until you are notified in writing by the BOE that your request has been approved date for making EFT payments DBA (Doing Business As)BUSINESS PHONE NUMBER EFT payments DO NOT attempt to pay by EFT before your approved start date For EFT assistance please call 800 400 7115 (TDD/TTY: 800 735 2929) General Graphic of a VOIDED check If the ACH Debit method is chosen a voided check must be attached to this completed form Your voided check will verify bank If you are submitting an authorization agreement form to change from ACH Debit to ACH Credit or vice versa you must If you are submitting an authorization agreement form to change your bank account or routing number you will not receive a Important Information IMPORTANT:If you have selected the ACH Debit option you must attach a voided check for the account to be debited Your voidedcheck Instructions for Completing the EFT Authorization Agreement Form Make a copy for your records make payments by EFT until the BOE notifies you in writing that your request has been approved and indicates the ending New EFT account number Remember to mark the word void across the face of the check that you return with the authorization agreement Once you are registered you cannot withdraw from the EFT program unless your average monthly tax over a 12 month participant until the BOE and I mutually agree to terminate my voluntary participation in the EFT program period is less than $20 000 If you qualify and wish to withdraw you must make your request in writing You must continue to Please check appropriate boxes:Change EFT reporting methodChange bank account on Please type or print clearly and return this form to the BOE promptly Be sure to make a copy for your records PRINT NAME OF SIGNER AND CAPACITY INWHICH SIGNED Return this form to the State Board of Equalization SpecialTaxes and Fees P O Box 942879 Sacramento CA 94279 0088 ROUTING NUMBER Savings Section I SECTION II SECTION III Sections II and III See reverse for instructions on completing this authorization agreement SIGNATURE OF TAXPAYER OR AUTHORIZED REPRESENTATIVE TITLE OF SIGNER SIGNATURE OF TAXPAYER OR AUTHORIZED REPRESENTATIVETITLE OF SIGNER TAXPAYER NAME The Board of Equalization (BOE) is herebyauthorized to initiate debit entries to the bank account identified belowand the bank is authorizedto debit suchaccount This authority is to remain in full force until EFT payments are no longer required bystatute or if I am avoluntary The BOE is hereby requested to grant authority for the above named taxpayer to initiate ACH credit transactions to the BOE s bank account The example of a voided check shown below indicates where to locate the routing number for your bank and your bank account These payments must be in the NACHA CCD+ format using the Tax Payment Convention (TXP) and may only be initiated for EFT taxpayments to the BOE provided for by statute Type of Account will verify bank account and routing numbers If you are unable to provide a voidedcheck a bank specification sheet may beused instead of the voided check You will be notified in writing if your agreement is approved Your confirmation letter will indicate when you must start making