Form Dr 5774 - Eft Authorization Individual Income Tax

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DR 5774 (02/26/09) Web
COLORADO DEPARTMENT OF REVENUE
DenveR, CO 80261
EFT AUTHORIZATION INDIVIDUAL INCOME TAX
Pay your income taxes electronically! By accessing our eFT Payments web site or making one phone call, you can pay
your estimated tax without writing a check or paying for postage. You can also make payments for electronically filed in-
come tax returns or extension payments. The funds can be withdrawn as soon as the following day or you may specify a
payment date up to a year in the future.
To sign up, fill out the information below and send to:
Colorado Department of Revenue
CDO Research, Room 309
Denver, CO 80261
EFT Number
___ ___ ___ ___ ___ ___ ___ ___ ___ ___
To be assigned by Department of Revenue
Taxpayer name
1204
1304
1404
Mailing Address
Social Security number
City
State
ZIP
Contact Person
Phone
(
)
email Address
I authorize the Colorado Department of Revenue to initiate debits to my account number __________________________________________________
Financial Institution name
Financial Institution Routing number
name on Financial Institution Account
Type of Account
Checking
Savings
Signature
Date
A VOIDED CHECK FOR THE BANK ACCOUNT INDICATED ABOVE must ACCOMPANy APPLICATION
Sample Check:
9 Digit Routing Number

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