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13 DIGITS) See Special Instructions on Back. Business Name: Name and Telephone Number of Individual in your Organization that Revenue may contact regarding EFT: Contact Person: (Please print) (Not a Bank contact) EFT Required or Voluntary Address: City, State, Zip: Telephone: FOR TAX TYPE: Please complete a separate form for each Tax Type selected Sales (RST) Financial Institution (FIT) Tire Fee (TIF) Utility Receipts Tax (URT) Withholding (WTH) Gasoline Distributors (MFT) Prepaid Sal.

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