Philadelphia Ez-Pay Ach Debit Payment Form - City Of Philadelphia Department Of Revenue

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City of Philadelphia
Electronic Funds Transfer (EFT)
Philadelphia EZ-Pay
ACH Debit Payment Form
Date
Time
Total Payment
Reporting ID Number
Password
‫ٱٱٱٱٱٱٱٱٱٱٱ‬
Reference Number
‫ٱ ٱ ٱ ٱ ٱ‬
Account # _________________________________________________________________________
Tax Type _________________________________________________________________________
Period/Year ________________________________________________________________________
Tax Due ___________________________________________________________________________
Interest & Penalty ___________________________________________________________________
Total Payment ______________________________________________________________________
Effective Date ______________________________________________________________________
Verification Code (calculate below) _____________________________________________________
Verification Code
‫ٱ ٱ‬
A.
Count the number of digits in the payment amount.
‫ٱ ٱ‬
B.
Add the value of each digit.
‫ٱ ٱ‬
TOTAL
C.
Add A and B together.
This is your verification code.
KEEP THIS FORM FOR YOUR RECORDS
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