Form                     North Dakota Office of State Tax Commissioner
 301-EF   ACH Credit Authorization

 Income Tax Withholding Only
                                                                                               FOR OFFICE USE ONLY
         New ACH Credit
         Change contact name/address
         Change payroll service information

Please print.  See reverse for instructions.

Section 1 - Taxpayer Information
1. Taxpayer Legal Name

2. Doing Business As Name (if different from line 1)

3. Mailing Address

4. City, State & Zip

5. Contact Person for E-File

6. E-Mail Address for Contact Person

7. Phone Number for Contact Person

8. State Withholding Account Number  (Your 9-digit federal ID plus the State's 2-digit suffix)

                                                                           Complete this section only if a payroll service will be making your payments
Section 2 - Payroll Service Information                                    [or if you are a payroll service preparing this form for the taxpayer. ]
*NameYourof9-digitPayroll Servicefederal ID plus the State's 2-digit suffix   Contact Person

Mailing Address                                                               Telephone Number for Contact Person

City, State & Zip                                                             E-Mail Address for Contact Person

Section 3 - Taxpayer Signature
This form does not provide on-line access to your withholding account information.  For on-line access, please see instructions.  By signing below, I understand I
have requested permission to file withholding tax returns and remit payment electronically via an ACH credit transaction I must initiate through my bank.  I have contacted
my bank and confirmed the bank can initiate ACH credit transactions that meet the State's requirements.  I understand the ACH credit transaction must be in the NACHA
standards format using the TXP convention to facilitate the proper posting of the credit.  I agree to follow the instructions set forth in the income tax withholding guideline
and on the reverse side of this form.  I also understand by completing the Payroll Service Information Section, I have designated the Payroll Service to act as my authorized
representative in matters related to the filing of my withholding tax returns with the State, including the disclosure of confidential withholding tax information on file with
the State.  Once I have been approved to file electronically using an ACH Credit, I will not receive a paper return from the State, and will be required to file and pay using
the ACH credit method for each tax period.  This authorization to participate is in effect until it is terminated by either party.

Taxpayer's Signature:                                                                                                             Date:
                                                             (Authorized Officer or Individual)
Print Name:                                                                                                                       Title:

Note:  If this form is being completed by a Payroll Service on behalf of the taxpayer, the taxpayer's authorized signature
must be obtained for us to disclose information unless there is a Form 500 on file with our office.

Mail to:   Office of State Tax Commissioner                                   Contact:   Phone: 701.328.1241
             Business Registration                                                                 Fax: 701.328.0332
             600 E. Boulevard Ave. Dept. 127                                                      E-mail: taxregistration@nd.gov
             Bismarck, ND 58505-0599                                                            Website: www.nd.gov/tax

301-EF Instructions

Employers must have an active income tax withholding account with the Offi ce of State Tax 
Commissioner before fi ling electronically.  Go to www.nd.gov/tax/tap and select Apply for Sales 
& Use or Withholding to obtain an account or to re-open an account.
  
Two methods are available to fi le income tax withholding returns electronically:

 • Taxpayer Access Point (TAP) – Returns and payments are submitted online.  TAP provides 
   access to online features that allow authorized users to view previously fi led returns and 
   payments, upload or key W-2 information, change fi ling methods, and add or delete user’s 
   access.  To register online go to www.nd.gov/tax/tap and sign up for access. 

 • ACH Credit (Withholding E-File) – An ACH Credit is an electronic transfer of funds 
   where you instruct your bank to transfer payment from your account to the state’s bank 
   account.  The ACH Credit contains return information and, therefore, also serves as the 
   return.  Registration may be completed by submitting this paper form. Registration using 
   this paper form does not provide you access to TAP to view previously fi led returns.  Tax 
   Payment Banking (TXP) addenda record layout is required for Income Tax Withholding 
   returns and is available at www.nd.gov/tax.  

Helpful Hints for the Form
  •  Complete all questions to avoid any delay.
  •  The E-File contact person should be the person who will actually be involved in initiating 
   and making the electronic fi ling of your return.  Be sure to include a phone number.
  •  If you are a Payroll Service completing the application on behalf of a taxpayer, be sure to 
   have the taxpayer sign and date the form at the bottom of Section 3.
   o  Exception:  If a properly completed Form 500 Authorization to Disclose Tax 
   Information and Designation of Representative has been submitted by the taxpayer, no 
   signature is required. 

28206 (January 2016)