Authorization Agreement For Direct Payment - Maine Revenue Services

Maine Revenue Services

Individual Income Tax

EFT Debit Affirmation

AUTHORIZATION AGREEMENT FOR DIRECT PAYMENT (EFT DEBIT)

Taxpayer Name

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SSN

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Date

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I hereby authorize Maine Revenue Services to initiate debit entries in the amount of

${auto fill} to my

o Checking

o Savings

account indicated below at the financial institution named below.

Bank Name:

Nine-digit routing number:

Bank account number:

The EFT Debit Transaction will be initiated immediately after successful transmission of

your 1999 Maine Individual Income Tax Return. Expect the amount to be debited no

later than 3 business days from the date of successful transmission.

Do not mail this form to Maine Revenue Services. Retain this form with your tax

records.

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