Connecticut Department of Labor
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ACH Credit Payment Registration Form

You are applying to send Connecticut Unemployment Insurance tax or reimbursement payments via ACH credit. Please complete the following information.

Connecticut Registration Number:  --
Federal Identification Number: -
Employer Name: 
Employer Address: 
City, State, Zip: 
ACH Contact Name: 
Phone Number:  --
E-mail Address: 

For the ACH Credit payment option, you will be responsible for contacting your bank, indicating the amount you want sent and having the transaction completed timely for funds to be received by the Connecticut Department of Labor on or before the ACH due date. I hereby request the Connecticut Department of Labor to grant authority for the above-named taxpayer to initiate ACH Credit transactions to the State Treasurer's bank account. I understand these must be in the NACHA CCD+ format using the TXP convention.

I have read and agree to the above instructions.


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