Form Dr 5774 - Eft Authorization Individual Income Tax

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DR 5774 (10/00)
EFT AUTHORIZATION
EFT Number
COLORADO DEPARTMENT OF REVENUE
DENVER CO 80261-0005
3 7 1 0
INDIVIDUAL INCOME TAX
___ ___ ___ ___ ___ ___ ___ ___ ___ ___
(303) 866-2388
To be assigned by Department of Revenue
Taxpayer Name
01204
Mailing Address
Social Security Number
City
State
ZIP
Contact Person
Phone
(
)
I authorize the Colorado Department of Revenue,
pursuant to my instructions, to initiate entries to my account number ________________________ at __________________________________ bank.
Name of Bank Account
Type of Account
Checking
Savings
Bank Transit/Routing Number
Signature
Date
A VOIDED CHECK FOR THE BANK ACCOUNT INDICATED ABOVE MUST ACCOMPANY APPLICATION

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