ROBERT SPRAGUE 
                                            TREASURER OF STATE  
                                            Authorization Agreement                                                                                                    
                                            Electronic Funds Transfer                                                                                                     
                                                                                                             
                      PLEASE COMPLETE ONE AGREEMENT PER SST ID NUMBER 
Part I  TAXPAYER INFORMATION  (REQUIRED)    Federal ID Number 
Please type or print information 
Taxpayer Name                               Contact Person 
                                             
Mailing Address (Street Number, Box Number) Telephone Number 
                                             
City, State, Zip Code                       Fax Number 
                                             
E-mail Address                               
                                             
Part II  TAX TYPE                            NEW ACCOUNT                               MODIFY ACCOUNT □      □
 
STREAMLINE SALES TAX ID  
 
#  S                                                                                                      □ STREAMLINE  SALES TAX  (SST)                                                                                              
 
Part III ACH CREDIT OPTION 
I hereby request Ohio Treasurer Robert Sprague’s Office to grant authority for the above named taxpayer to initiate ACH Credit 
Transactions to Ohio Treasurer Robert Sprague’s Office bank account.  It is understood that these transactions must be in the NACHA 
CCD+ format using the TXP Payment Convention and may only be initiated for the tax type specified above. 
 
Authorized Signature                                                                                                       Date 
 
MAIL: Ohio Treasurer Robert Sprague                   www.eft.tos.ohio.gov                                         Questions: Ohio Treasurer Robert Sprague 
Attn: Electronic Payments Unit                                                                                                                            EFT Help Line 
30 East Broad Street, 9  Floor                                                                                                                             1-877-EFT-OHIO th
Columbus, Ohio  43215-3461                                                                                                                                FAX :  (614) 752-5377   

    Revised 05/2007