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Get IA 470-0254 2015-2024

Page 2 Payment Information 11. Payment method: a. Check one box: An Electronic Funds Transfer (EFT) Authorization Form is required if you will be enrolling using a Federal Employer Identification Number (FEIN) of the business. A debit card is only an option if an individual is doing business under a Social Security Number in box 2. b. Enter the pay-to address: This address is used for mailing of the debit card and 1099s. Pharmacies Only 12. Pharmacies only enter: a. The National Council for Pr.

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