Form A-771a - Electronic Funds Transfer Authorization

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Wisconsin Department of Revenue
Electronic Funds Transfer Authorization
2135 Rimrock Rd
PO Box 8901
Madison WI 53708-8901
This form must be completed and signed by the person
Phone: (608) 266-7879
authorizing the Electronic Funds Transfer from their account.
Fax: (608) 261-8978
delnqtax@dor.state.wi.us
Click mouse in box below and enter Taxpayer Name. Tab throughout rest of form.
Taxpayer Name(s)
Address
City
State Zip Code
Social Security Number or EIN
Phone Number
(
)
I authorize and direct the State of Wisconsin, Department of Revenue to initiate withdrawal from the account
described as follows:
Name of Financial Institution
Account Name
(check one) è
Account Number
Checking
Savings
Routing Transit Number
Your account number and 9-digit routing transit number are on the bottom edge of your check, or call your financial institution for
assistance.
Amount to be withdrawn $
(check one) è
th
th
th
The day the Electronic Funds Transfers are to be made
5
15
25
of each month.
* * Attach a voided check or other account verification to this form * *
The payment amount, specified in the Installment Agreement between the taxpayer (identified above) and the Department of
Revenue, will be the authorized amount of the monthly Electronic Funds Transfer. The date that the monthly Electronic
Funds Transfers are to be made on is indicated above. If this date falls on a day which is not available for transfer, the
authorized day of transfer will be the next available day. This authorization will remain in effect until cancellation by me, in
writing to the Department of Revenue, or until the amount due, as specified in the Installment Agreement, is fully paid. It may
take up to two weeks to process my request to cancel my authorization.
If a withdrawal cannot be completed because funds are unavailable in my account, I will be subject to any overdraft fees that
the Department of Revenue or my financial institution may charge.
AUTHORIZED BY:
Authorized Signer Name (please print)
Authorized Signer Name (please print)
Signature
Signature
Date
Date
A-771a (N. 7-02)

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