Transcription of ACH Debit Pre-Note Authorization Request
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ACH Debit Pre-Note Authorization Request
Employment Security DivisionContributions Section500 East Third StreetCarson City, NV 89713-0030(775) 684-6300*0*0 suspected UI Fraud online at orcall (775) 684-0475*RPT7011*RPT7011 ACH Debit Pre-Note Authorization RequestNew RequestChange Bank Acct/Routing #Change Threshold AmountChange Contact InfoINSTRUCTIONS: Please complete this Request and mail to the address above, or fax to (775) 684-6351. A VOIDED CHECKOR BANK SPECIFICATION SHEET MUST BE INCLUDED. The department must verify the account number and routingtransit numbers before granting Authorization . For security purposes you must also specify a threshold amount that eachpayment cannot exceed. The threshold amount should be greater than the highest single payment you anticipate making. Allrequired fields are indicated by an asterisk (*) and must be to be Debited From:CheckingOrSavings* Bank Account Number* Routing Number of Banking Institution*Threshold: Do not authorize any transfer amount over $ over this threshold amount will not be Unemployment Insurance Account to be Credited:Employer Account NumberEmployer Business Name**FEIN #_____Multiple Accounts?
Employment Security Division Contributions Section 500 East Third Street Carson City, NV 89713-0030 (775) 684-6300 *0* 0 https://uitax.nvdetr.org UI
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