TO PAY BY CREDIT CARD FILL IN BELOW
Total $
Card Number:
Exp. Date:
Signature:
Month
Year
ELECTRONIC REFUND OR PAYMENT INFORMATION
Mark one:
Refund-direct deposit
Pay tax due-electronic funds withdrawal
Effective date:
(if blank default is date return processed)
Routing number:__________________________
Account number:_________________________
Type of Account:
Checking
Savings
THIRD PARTY DESIGNEE
Do you want to allow another person to discuss this return with the Income Tax Department?
Yes*
No
*If yes complete the following:
Designee's Name
Phone No.
Personal Identification Number (PIN)
PLEASE SIGN YOUR RETURN BELOW AND ATTACH COMPLETE COPY OF FEDERAL FORM 1065
I declare that I have examined this return (including accompanying schedules and statements) and to the best of my
knowledge and belief it is true, correct and complete. If prepared by a person other than taxpayer, his/her declaration is
based on all information of which he/she has any knowledge.
SIGN HERE
Phone number
Date
(Signature of partner or member)
SIGN HERE
Address
Date
(Signature of preparer other than partner or member)