Form Eft-1 - Authorization Agreement For Certain Electronic Payments
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1
2Illinois Department of Revenue
EFT‑1
Authorization Agreement for Certain Electronic Payments
Read this information first:
Complete this form ONLY if you 1) want to pay amounts owed to the Illinois Department of Revenue
using ACH credit; pay-by-phone debit; direct file debit for telecommunications, tobacco, and liquor; or cigarette tax stamp purchase debit; or 2)
are changing previously submitted information about one of the methods of payment listed above. Note: For most taxes, electronic payments
can be made easily on our website at tax.illinois.gov using MyTax Illinois (do not complete Form EFT-1 if you pay using MyTax Illinois).
Step 1: Complete the following information
1
2
Check the payment method you wish to use (or wish to update).
Check the reason you are completing this form.
a
ACH credit
Initial set up (Check this box and skip to Step 2.)
b
Pay-by-phone debit
Change to previously submitted information
3
If a change, write the effective date. ____/____/________
Direct file debit for telecommunications, tobacco
,
c
and liquor
4
Explain the change:___________________________
d
Cigarette tax stamp purchase debit
(required method for RC-1-A)
Step 2: Identify yourself
5
7 ___ ___ ‑ ___ ___ ___ ___ ___ ___ ___
_________________________________________________
Taxpayer’s name
Federal employer identification number (FEIN)
6
8 ___ ___ ___ ‑ ___ ___ ‑ ___ ___ ___ ___
_________________________________________________
Address
Social Security number (SSN)
_________________________________________________
City
State
ZIP
Step 3: Complete designated agent or contact person information
9
11
_________________________________________________
(_____)_________________ (_____)__________________
Designated agent’s or contact person’s name
Telephone
Fax
10
12
_________________________________________________
_________________________________________________
Address
Email address
13
_________________________________________________
_________________________________________________
City
State
ZIP
Signature authorization (authorized officer of designated agent or contact person)
Step 4: Check the taxes for which you wish to authorize these payments
Illinois income taxes:
Excise taxes continued:
Individual Income Tax
_____________________
Electricity Excise Tax
_____________________
Illinois Account ID number
Illinois Account ID number
Withholding Income Tax
_____________________
Gas Revenue/Gas Use Tax
_____________________
Illinois Account ID number
Illinois Account ID number
Hotel Operators’ Occupation Tax
_____________________
Business Income Tax
_____________________
Illinois Account ID number
Illinois Account ID number
Sales taxes:
Liquor Tax - Airline
_____________________
Illinois Account ID number
Sales/Use Tax & E911 Surcharge
_____________________
Liquor Tax - Importer/MFTR/Dist
_____________________
Illinois Account ID number
Illinois Account ID number
Chicago Soft Drink Tax
_____________________
Liquor Tax - Direct Wine Shipper
_____________________
Illinois Account ID number
Illinois Account ID number
County Motor Fuel Tax
_____________________
Motor Fuel Tax-Dist./Supplier
_____________________
Illinois Account ID number
(ACH credit only)
Illinois Account ID number
MPEA Food and Beverage Tax
_____________________
Motor Fuel Tax-UST/EIF Receiver _____________________
Illinois Account ID number
(ACH credit only)
Illinois Account ID number
Prepaid Sales Tax (motor fuel)
_____________________
Motor Fuel Tax-Alternative Fuels
_____________________
Illinois Account ID number
(ACH credit only)
Illinois Account ID number
Automobile Renting Tax
_____________________
Telecommunications Excise Tax
_____________________
Illinois Account ID number
Illinois Account ID number
Excise taxes:
Telecom Infrastruct. Maint. Fee
_____________________
Cigarette Tax Stamp Purchase
_____________________
Illinois Account ID number
(Debit only)
Illinois Account ID number
Tobacco Products Tax
_____________________
Electricity Distribution and
Illinois Account ID number
Invested Capital Tax
_____________________
Illinois Account ID number
EFT-1 front (R-06/16)
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Parent category: Financial