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Payment and Authorization Agreement
FORM
27D
for Electronic Funds Transfer (EFT) of Tax Payments
• Read instructions on reverse side.
BUSINESS NAME AND LOCATION ADDRESS (if applicable)
TAXPAYER NAME AND ADDRESS
Name
Name
Street Address
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
Nebraska ID Number
Federal ID Number
Daytime Phone
Home Phone
Social Security Number
Spouse’s Social Security Number
Nebraska Department of Revenue Agent Name/Phone Number
Delinquent Tax Programs:
22 — Individual
21 — Withholding
24 — Corporation
01 — Sales and Use Tax
Other:
Purpose of This Form:
Set Up EFT Account
Change EFT Account Information
Terminate EFT Authorization
Total Liability
Tax Periods of Delinquency
Date Interest Computed Through
$
SECTION I — Income
Name of Your Employer
Length of Employment
Date Paid
Gross Monthly Wages
Net Monthly Wages
$
$
Name of Spouse’s Employer
Length of Employment
Date Paid
Gross Monthly Wages
Net Monthly Wages
$
$
Other income (include child support, alimony, interest, etc.). Specify sources.
Amount
$
$
Total Monthly Net Income ...........................................................................................................................................................
SECTION II — Payment Proposal
I/we propose to make payments as follows: $ ______________________ starting ____________________________.
Payments will be made:
Weekly
Bi-Weekly
1st & 15th
Monthly
Last Day of Month
If this agreement is approved, payments will be made using EFT. All state taxes and returns will be filed and paid in a timely manner during the terms of this
agreement. Any overpayment that might otherwise be refunded will be applied to this liability until the liability is paid in full.
SECTION III — Financial Institution Account Information
I/we authorize and direct the Nebraska Department of Revenue, to initiate a withdrawal from my/our account, described as follows:
Financial Institution Name and Address
Routing Transit Number
Names on Account
Account Number
Type of Account
Checking
Savings
A VOIDED CHECK MUST BE ATTACHED FOR CHECKING ACCOUNTS.
This authorization will remain in effect until cancellation, in writing, to the Nebraska Department of Revenue.
If a withdrawal cannot be completed because funds are unavailable in the account, I/we will be subject to any overdraft fees that the financial institution may
charge. See instructions on reverse side for important information.
SECTION IV — Authorization
I/we hereby authorize the Nebraska Department of Revenue (Department), upon my/our initiation only, to accept Automated
Clearing House (ACH) transactions as payment on this account. I/we also authorize the Department to release any of the above taxpayer
and financial institution information, as deemed necessary, to enable payment by EFT. This authorization is to remain in full force and
effect until the Department has received written notification from the taxpayer of its termination. The Department reserves the right to
terminate this agreement at its sole discretion.
sign
Authorized Signature
here
Date
Title
Authorized Signature (Spouse)
Date
Title
E-Mail Address
APPROVED
Authorized Signature — Department of Revenue
Title
Date
Mail this form with a VOIDED check/deposit slip to:
7-242-1996 Rev. 5-2010
NEBRASKA DEPARTMENT OF REVENUE, P.O. BOX 94609, LINCOLN, NE 68509-4609
Supersedes 7-242-1996 Rev. 4-2008