Department of Revenue Services
Form CT-1040 EFW
2014
State of Connecticut
Connecticut Electronic Withdrawal Payment Record
(Rev. 12/14)
Do not mail this form to the Department of Revenue Services (DRS).
Keep this form as verifi cation that electronic payment to DRS was requested for the 2014 taxable year.
If the funds for payment will come from a banking institution outside of the United States,
the payment must be made by paper check.
Primary Social Security Number
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Secondary Social Security Number
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Routing transit number
Bank account number
Type of account
1 = Checking; 2 = Savings
Amount of payment
Type of return
C T -
Request payment date
Taxpayer’s daytime telephone number