Authorization To Honor Drafts/ Automated Clearing House Debits For Deferred Payment Plans Form

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REV-692 FO (07-13)
Authorization to Honor Drafts/
Automated Clearing House Debits for
Bureau of Collections and
Taxpayer Services
Deferred Payment Plans
See reverse for instructions.
START
To:
Financial Institution Name
Address (Main Office)
City
State
ZIP Code
Routing Number
Account Type
Checking
Savings
Account Number
From: Account Owner (Individual or Company Name)
Identification Number
Owner’s Federal Employer Identification Number (FEIN)
or Social Security Number: (SSN) . . . . . . . . . . . . . . . . .
I (we) request and authorize the financial institution named above to charge to the above-identified
account drafts/ACH debits payable to the PA Department of Revenue, Harrisburg, PA 17128.
I (we) agree that the authenticity of a payment order from the PA Department of Revenue need not be
verified. I (we) further agree that a payment order from the PA Department of Revenue is authorized until
revoked, in writing, to both the financial institution and the PA Department of Revenue.
If the PA Department of Revenue cannot deduct the monthly payment from my (our) account due to
insufficient funds or account closure, my (our) payment agreement will be cancelled and a penalty will be
imposed. I understand that if verbal authorization has already been granted to the department, the ACH
debits will begin, regardless of completion and return of this form.
PLEASE SIGN AFTER PRINTING FORM
Date
Signature of Account Owner(s)
MM/DD/YYYY
(If two signatures required on financial institution authorizations, both signatures are necessary here.)
PLEASE SIGN AFTER PRINTING FORM
(
)
Telephone Number, including Area Code
Reset Entire Form
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SEE INSTRUCTIONS ON REVERSE
PRINT FORM

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