Skip to main content
  • State of Arizona
  • Visit OpenBooks
  • Ombudsman Citizens Aide
  • Register to Vote
Home
Industrial Commission of Arizona
Protection of life, health, safety, and welfare of Arizona's workforce

Main navigation

  • Home
  • About
    • Arizona Rules
    • Arizona Statutes
    • Commissioners
    • Director's Office
    • Meetings
  • Divisions
    • Administration
      • Accounting
      • Human Resources
      • Special Services and Procurement
    • Administrative Law Judge (ALJ) Division
    • Arizona Division of Occupational Safety and Health (ADOSH)
      • Boiler Safety Section
      • Elevator Section
      • Research & Statistics (BLS)
    • Claims Division
    • Labor Department
    • Legal Division
    • Medical Resource Office (MRO)
    • Special Fund Division
  • News
    • News
    • Public Notices
  • Resources
    • Resources for Employees
    • Resources for Employers
    • Resources for Insurers
    • Resources for Medical Providers
    • Resources for ICA Community
    • Frequently Asked Questions
  • Online Services
    • Industrial Commission of Arizona Community
    • Industrial Commission of Arizona Forms
  • Payment
  • Ombudsman

User account menu

Log in
  1. Home
  2. Forms
  3. Reversal Form For Reversing Automated Payment Processing

Reversal Form for Reversing Automated Payment Processing

Instructions

This form must be submitted by the 5th Business Day from the cleared date of the ACH Payment. Once completed, email the form to the GAO AFIS Operations Group at: [email protected].

E-sign Electronic Submission Form

GAO State of Arizona ACH Vendor Authorization Form

Related Forms

Form Name
Insurance Carrier - Quarterly Tax Form
Insurance Carrier - Annual Tax Form 200
Self-Insured Employer - Quarterly Tax Form
Self-Insured Employer - Annual Payroll Report Form
Self-Insured Employer - Annual Medical Report Form
Self-Insurer Request for Extension to File Tax Forms
Self-Insured Employer - Annual Injury Report Form
Self-Insured Employer - Annual Hospital Report Form
Reversal Form for Reversing Automated Payment Processing
State of Arizona Substitute W-9 and ACH Vendor Authorization Forms & Instructions
Official Seal of the State of Arizona

Contact

Phoenix Office
800 W. Washington Street
Phoenix, AZ 85007

 

Tucson Office
2675 E. Broadway Blvd
Tucson AZ 85716

 

Phoenix: (602) 542-4661
Tucson: (520) 628-5188

Footer

  • Statewide Policies
  • Website accessibility
  • Content disclaimer
  • Privacy policy
  • Security
  • Sitemap
  • The Ombudsman-citizens Aide Helps Citizens to Resolve Ongoing Issues With State Agencies