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DR 5785 (07/14/22)
COLORADO DEPARTMENT OF REVENUE
Pierce Cashiers Room 132
P.O. Box 173350
Denver CO 80217-3350
EFT Number
Electronic Funds Transfer (EFT)
Account Setup For Tax Payments To be assigned by Department of Revenue
Taxpayer Name Contact Person
Set Up New Account
Mailing Address (Street Number, Apt. Number, Box Number) FEIN or Social Security Number
Modify Account
Telephone Number
Add Taxes
City, State, ZIP Fax Number
Remove Taxes
Email Address
Add Additional EFT Number(s)
Tax To Be Paid by EFT Transactions.
Must be completed for either ACH debit or ACH credit.
See listing of taxes and tax type codes on reverse side.
Tax Type Tax Type Code Your DOR Account
Complete Section 1 and/or 2
Section 1—ACH Debit
ACH Debit—taxpayer selects the EFT payment option on our web page or calls a toll free number
I hereby authorize the Colorado Department of Revenue (DOR), to initiate debit entries to my banking account. This
authority is to remain in full force and effect until DOR and Financial Institution have received written notification
from me of its termination in such time and in such manner as to afford DOR and FI a reasonable time to act
on it. The use of an EFT identification number and password will be required to convey my instructions for each
transaction. The EFT identification number and password may be used by me or by my agent. You will be able to
provide your banking information 24 hours after your registration for EFT.
Authorized Signature Title Date (MM/DD/YY)
Section 2—ACH Credit
ACH Credit —taxpayer initiates through own financial institution.
I have contacted my financial institution and confirmed the financial institution can initiate Automated Clearing House
credit transactions that meet Colorado Department of Revenue (DOR) requirements. For verification, DOR may contact:
Name of Bank Bank Contact Person Telephone Number
I hereby request DOR grant authority for the above named taxpayer to initiate Automated Clearing House credit
transactions to DOR's bank account. I understand these must be in the NACHA CCD+ format using the Tax Payment
(TXP) Convention or the Third Party Payment (TPP) Convention. May only be initiated for the tax types that have
been registered for EFT payments with DOR.
Authorized Signature Title Date (MM/DD/YY)
Please return application to: Colorado Department of Revenue, P.O. Box 173350, Denver CO 80217-3350,
Fax: (303) 205-5779. Email: dor_afs_piercecashiers@state.co.us
