Automatic Payment Plan Authorization Agreement Form - Delaware Division Of Revenue

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AUTOMATIC PAYMENT PLAN AUTHORIZATION AGREEMENT
Note –
In order to process your request quickly and efficiently, you must include a voided check or savings
deposit slip with your completed authorization form. Thank you.
1. NAME OF YOUR BANK,SAVING AND LOAN OR CREDIT UNION
2. TRANSIT/ABA NO.
__________________________________________________________
_______________________________________________________
3. BRANCH
4. DAYTIME PHONE NUMBER
_____________________________________________________________________________
__________________________________________________________________________
5. SAVINGS OR CHECKING ACCOUNT NUMBER
6. ACCOUNT NUMBER AS SHOWN ON DIVISION OF REVENUE
BILL
_____________________________________________________________________________
_______________________________________________________
CHECKING
__ SAVINGS
__
7. YOUR NAME ON FINANCIAL INSTITUTION RECORDS
8. YOUR ADDRESS AS IT APPEARS ON FINANCIAL INSTITUTION
RECORDS
STREET_______________________________________________
_______________________________________________________________________________
CITY_____________________STATE_______ZIP_____________
____________________________________________________________
9. SIGNATURE(S) AS SHOWN ON FINANCIAL INSTITUTION
RECORDS
Official Use Only
Social Security Number
Authorized Signature(s)
Taxpayer Identification No. ___________________________
__________________________
________________________________________________
Revenue Code
___________________________
__________________________
_________________________________________________
_______________________________________________________________________________
Tax Type
___________________________
10. DATE _____________________________________________
Tax Period End
___________________________
I (WE) AUTHORIZE THE DELAWARE DIVISION OF REVENUE TO
Amount
___________________________
INITIATE DEBIT ENTRIES TO MY (OUR) ACCOUNT INDICATED AND
THE BANK, SAVINGS AND LOAN OR CREDIT UNION, TO DEBIT THE
Payment Date
___________________________
SAME TO SUCH ACCOUNT.
THIS AUTHORIZATION TO REMAIN IN FULL FORCE AND EFFECT
UNTIL THE DELAWARE DIVISION OF REVENUE HAS RECEIVED
WRITTEN NOTIFICATION FROM ME (OR EITHER OF US) AS TO ITS
TERMINATION IN SUCH TIME AND IN SUCH MANNER AS TO AFFORD
THE DELAWARE DIVISION OF REVENUE AND THE FINANCIAL
INSTITUTION A REASONABLE OPPORTUNITY TO ACT UPON IT.

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