Form 42a740-Epay - Electronic Payment Request Form - Department Of Revenue

Instructions for Form EPAY

Kentucky Electronic Payment Request Form

be later than the scheduled date. Please

electronic payment request to verify and

Purpose of Form

confirm that the information is correct

allow up to two weeks for processing.

The purpose of this form is to authorize

and that the taxpayer agrees to the

the Kentucky Department of Revenue and

Payment of Estimated Tax for Tax Year

withdrawal.

its designated Financial Agent to initiate

2017

an ACH electronic funds withdrawal to the

EROs and tax preparers are prohibited

Entries in this section allow you to

from obtaining taxpayer signatures on

financial institution account indicated by

the taxpayer for payment of taxes and

schedule withdrawals from the account

blank or incomplete forms.

estimate tax other than at the time of

specified in the financial institution

filing the individual income tax return.

information for estimate tax for the

Declaration and Signature of Electronic

If the request is being made at the time

upcoming tax year. You can choose

Return Originator and Paid Preparer

of filing the individual income tax return,

to make one to four equal payments

the Form 8879-K, Kentucky Individual

depending upon the debit dates selected.

This section must be completed and

signed by the ERO and paid preparer.

Income Tax Declaration For Electronic

Filing should be completed.

For example, if you select September 15,

If the ERO is also the paid preparer, the

2017 and January 16, 2018 on line 5 and

Completing the Form

enter $50 on line 6, $50 will be withdrawn

ERO must check the paid preparer box,

but is not required to complete or sign

on September 15, 2017 and $50 will be

withdrawn on January 16, 2018.

the paid preparer information.

Submission Identification Number (SID)

E n t e r t h e 2 0 - d i g i t S u b m i s s i o n

Line 5—Select the date(s) you want the

A paid preparer who is not the ERO

Identification Number (SID) assigned

payment to be withdrawn from your

must complete, sign and date the paid

account. Up to four equal payments may

preparer information.

by the software.

be selected by choosing the appropriate

Do not mail the form. Complete the form

boxes. Actual withdrawal of funds may

and retain for a period of three years. If

be later than the scheduled date. Please

the taxpayer is using an ERO, it is the

allow two weeks for processing.

responsibility of the ERO to obtain the

signature of the taxpayer(s), retain the

Line 6—Enter the amount that will be

withdrawn from your account on each

form and provide the taxpayer with a

copy of the signed form.

of the dates selected on line 5.

Name, Social Security Number and

Financial Institution Information

Address

This section is required in order to

Enter your last name, first name, middle

process the payment.

initial, social security number and

mailing address.

Line 7—Enter your financial institution’s

routing number. The routing number

Payment Information

must be 9-digits and begin with 01

through 12 or 21 through 32.

Select the type of payment(s) you would

like to make.

Line 8—Enter the account you wish the

payment to be withdrawn from. The

Payment of Tax Due

account number can be up to 17-digits

in length.

Include Notice Number, if applicable.

Line 9—Select the type of account the

Line 1—Enter the amount of tax you are

payment will be withdrawn from.

paying.

Line 10—Indicate whether your account

Line 2—Enter the total amount of

is located outside the United States. Due

penalties and interest you are paying.

to federal electronic banking regulations,

you must answer the question if you are

Line 3—Enter the amount to be debited

paying the amount you owe via direct

for the payment of tax due plus penalties

debit. Requests will not be processed for

accounts located outside the U.S.

and interest. This should be the sum of

line 1 and line 2.

Declaration of Taxpayer

Line 4—Enter the date you want the

payment to be withdrawn from your

The taxpayer must sign and date the

account. Actual withdrawal of funds may

Form EPAY prior to transmitting the

Form 42a740-Epay - Electronic Payment Request Form - Department Of Revenue - 2016 Page 2

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