COMMONWEALTH OF MASSACHUSETTS 
 EXECUTIVE OFFICE OF LABOR AND WORKFORCE DEVELOPMENT (EOLWD) 
              DIVISION OF UNEMPLOYMENT ASSISTANCE (DUA) 
                                        
              REGISTRATION TO PAY DUA TAXES VIA ACH CREDIT 
 
Company Name: __________________________________________________________ 
 
DUA Employer Number: ____________________________________________________ 
 
Federal Identification Number: _______________________________________________ 
 
Agent / PTP / Third Party?     Yes      No      Agent ID Number _________________ 
 
Street: _________________________________________________________________ 
 
City / State: __________________________________  Zip Code: _________________ 
 
Contact Person(s): ________________________________________________________ 
 
Email Address: _______________________________ 
 
Telephone Number(s): _________________________ 
 
Fax Number: _________________________________ 
 
Your Signature:_________________________________  Title:_________________________ 
 
Mail Form To: 
 
   Division of Unemployment Assistance 
                                               th
   Attn.: Bill McDonough, Revenue Service, 5  Floor 
   19 Staniford Street 
   Boston, MA  02114 
 
   Or 
 
   Fax To: 617-523-2334 
 
After submittal of this registration, you will be provided with the DUA mandated ACH credit 
record layout and DUA bank account and routing transit numbers. 
                                        
10/6/09