Application For Mass Debit Tax Payment - Massachusetts Department Of Revenue
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1Commonwealth of Massachusetts
Department of Revenue
Application for Mass Debit Tax Payment
(ACH debit option)
Company Information
Company name (as it appears on your tax return)
Federal Identification number (EIN)
Address
City/Town
State
Zip
E-mail address
Contact person
Social Security number
Telephone
Fax
Taxes to be paid electronically.
Check box for each tax you wish to pay electronically.
Trustee taxes mandated for combined annual liability exceeding $100,000
0166
Withholding
0136
Sales on telecommunications
0137
Sales and use tax
0138M Meals tax
0143
Room occupancy
_____
__________________
Locality code
City/Town
Corporate taxes mandated for annual liability exceeding $250,000
0167E Corporate — domestic (Massachusetts)
0168E Corporate — foreign (outside Mass.)
Banks and financial institutions excise tax mandated for annual liability exceeding $100,000
0133E Domestic banks
0134E Foreign banks
0132E Financial institutions
Insurance companies excise tax mandated for annual liability exceeding $100,000
0116E Insurance — preferred provider
0123E Insurance — domestic life
0119E Insurance — domestic/foreign premium
0124E Insurance — domestic life investment
privilege
0120E Insurance — foreign life, accident and health
Public services excise tax mandated for annual liability exceeding $100,000
0170E Public service — gas and electric
0173E Public service — telephone
0172E Public service — railroads
0174E Public service — power
Miscellaneous excise tax mandated for annual liability exceeding $100,000
0112M Gasoline
Voluntary electronic payments
0179
Fiduciary
If you selected ACH Debit for corporate excise (domestic or foreign), financial institution, insurance or public service, which
_____________________________________________________________
month does your fiscal year end?
Bank Information
Bank name
Transit/ABA number
Checking account number
Important: Attach a voided check for the checking account to be charged.
Authorization.
I hereby authorize Fleet Bank to provide my company with Mass Debit electronic tax payment services.
I agree to be bound by the Mass Debit Terms and Conditions, a copy of which I have received and read. I confirm that I am
authorized to sign this account.
Authorized signature
Date
Print name
Title
Return to: Massachusetts Department of Revenue, EDS/EBU Unit, PO Box 7013, Boston, MA 02204.
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