Maryland Form El101 Draft - E-File Declaration For Electronic Filing - 2013
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1
22013
e-File DECLARATION
MARYLAND
FORM
FOR ELECTRONIC FILING
EL101
Keep this form for your records. Do not send this form to the State of Maryland unless requested to do so. See Instructions on Page 2.
Taxpayer’s first name and middle initial
Last name
SSN/Taxpayer identification number
Spouse’s first name and middle initial
Last name
SSN/Taxpayer identification number
Present address (number and street)
City or town
State
ZIP code
Part I
Tax Return Information (whole dollars only)
|
1. Amount of overpayment to be applied to 2014 estimated tax . . . . . . . . . . . . . . . . . . . . . . . . . . .
1. _________________
|
2. Amount of overpayment to be refunded to you . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
REFUND
2. _________________
|
3. Total amount due (Pay in full by April 15, 2014. See instructions.) . . . . . . . . . . . . . . . . . . . . . . .
3. _________________
If you file your Maryland Income tax return electronically by 4/15/14, you have until 4/30/14 to make your electronic payment.
Direct deposit or direct debit options are not eligible for Amended returns.
Part II
Taxpayer Declaration and Signature Authorization
Check appropriate box to consent to:
Direct Deposit of refund or
Electronic Funds Withdrawal (direct debit)
|
1. Amount to be withdrawn from/deposited in first account . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. _________________
Routing number (9-digit) _ _ _ _ _ _ _ _ _
c
Checking
Savings
Account number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Direct Debit Settlement Date ____/____/____
(Enter the date you want your payment withdrawn from your account.)
|
2. Amount to be deposited in second account . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. _________________
Routing number (9-digit) _ _ _ _ _ _ _ _ _
c
Checking
Savings
Account number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
|
3. Amount to be deposited in third account . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. _________________
Routing number (9-digit) _ _ _ _ _ _ _ _ _
c
Checking
Savings
Account number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
4a.
I consent that my refund be directly deposited as designated above and declare the information shown is correct. The State
of Maryland is not responsible for a lost refund if I enter the incorrect account information. If I have filed a joint return, this
is an irrevocable appointment of the other spouse as an agent to receive the refund. By consenting, I also agree to disclose
to the Maryland State Treasurer's Office certain income tax information including name, amount of refund and bank
information. This disclosure is necessary to effect direct deposit.
4b.
I authorize the State of Maryland and its designated financial agent to initiate an electronic funds withdrawal payment (direct
debit) to the financial institution account indicated on above for payment of my Maryland and local taxes owed, and the
financial institution to debit the entry to this account. Upon confirmation of consent during the filing of my state return, this
authorization is to remain in full force and effect, and I may not terminate the authorization. I also authorize the financial
institutions involved in the processing of this electronic payment of taxes to receive confidential information necessary to
answer inquiries and resolve issues related to the payment.
4c.
I do not want direct deposit of my refund or an electronic funds withdrawal (direct debit) of my balance due.
Under penalties of perjury, I declare that I have compared the information contained on my electronic return with the information that I provided to
my electronic return originator or entered on-line and that the name(s), address and amounts described above agree with the amounts shown on the
corresponding lines of my 2013 Maryland electronic income tax return. To the best of my knowledge and belief, my return is true, correct and
complete. I consent that my return, including accompanying schedules and statements, be sent to the Maryland Revenue Administration Division by
my electronic return originator or by my electronic return software provider.
Please
Sign Here
Taxpayer’s signature
Date
Spouse’s signature (If joint return, both must sign.)
Date
Please wait ten (10) days after the receipt of a valid acknowledgement before calling 410-260-7701 from Central Maryland,
or 1-800-218-8160 from elsewhere, about your refund.
Part III Declaration of Electronic Return Originator (paid preparer)
I declare that I have reviewed the taxpayer’s return and that the entries on this form are complete and correct to the best of my knowledge. I have
obtained the taxpayer’s signature before submitting the return to the Maryland Revenue Administration Division, have provided the taxpayer with a
copy of all forms and information to be filed with the Maryland Revenue Administration Division, and have followed all other requirements described
in the Handbook for Electronic Filers of Maryland Income Tax Returns. This declaration is to be retained at the site of the electronic return originator.
Date
EFIN
Electronic
Originator’s
signature
Return
Originator
Firm’s name (or
Use Only
yours if self-
employed) and
ZIP code
Phone
address
COM/RAD-059
13-49
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