JOSH MANDEL 
                                                    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 Josh Mandel’s Office to grant authority for the above named taxpayer to initiate ACH Credit 
Transactions to Ohio Treasurer Josh Mandel’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 Josh Mandel                   www.eft.tos.ohio.gov                                         Questions: Ohio Treasurer Josh Mandel 
Attn: Electronic Payments Unit                                                                                                                            EFT Help Line 
30 East Broad Street, 9  Floor                                                                                                                            th1-877-EFT-OHIO 
Columbus, Ohio  43215-3461                                                                                                                                FAX :  (614) 752-5377   

                      Revised 05/2007