Form 27d - Payment And Authorization Agreement For Electronic Funds Transfer (Eft) Of Tax Payments - 1996 Page 2
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1
2INSTRUCTIONS
PURPOSE. The Payment and Authorization Agreement, Form 27D, is to be used when entering into a payment agreement
with the Nebraska Department of Revenue (Department). Your signature authorizes the Department to obtain agreed upon
payments through an electronic funds transfer (EFT) from your financial institution. With certain exceptions, this is the only
acceptable form of agreement the Department will allow for delinquent taxes.
WHO MUST FILE. This payment and authorization agreement must be completed by any taxpayer who wishes to enter into
a payment agreement with the Department, or by anyone who wishes to change or terminate an existing agreement.
WHEN AND WHERE TO FILE. This agreement must be received by the Department at least ten days prior to the due
date of the first installment. Send this agreement to: Nebraska Department of Revenue, P.O. Box 94609, Lincoln, Nebraska
68509‑4609. If you are in bankruptcy, do not file this form. Instead, call 402‑595‑2069 or 402‑595‑2070.
SPECIFIC INSTRUCTIONS. Business name and location address should be completed if this agreement is to resolve any
tax other than individual income taxes. Enter the name and address under which you do business.
Taxpayer name (name of corporation, partnership; if sole proprietorship or individual income tax, enter your full name) and
address must be completed by every taxpayer.
Complete your Nebraska Business Identification Number if you have been assigned one. Enter the federal identification
number if you have been assigned one. If no federal identification number is held, enter your social security number.
Check the appropriate boxes for the delinquent tax programs this agreement will resolve. Enter the total amount due, the
periods of delinquency, and the date interest has been computed through (refer to your most recent Balance Due Notice from
the Department).
SECTION I — INCOME
Complete this section and list the sources and amount of any income you or this business receives. Please list this income in
monthly figures. Attach additional sheets if necessary.
SECTION II — PAYMENT PROPOSAL
Enter the amount you will pay on a regular basis. These payments, if accepted, will be automatically deducted from your
account based on your authorization. Be sure the Department has this agreement at least ten days prior to your starting date
for these payments.
If the Department does not accept this proposal, a new proposal and a more detailed financial statement will be sent to you.
SECTION III — FINANCIAL INSTITUTION ACCOUNT INFORMATION
(See diagrams in next column.)
Enter: (1) the name and address of the financial institution from which you want these payments deducted; (2) the exact name
shown on your account; (3) the account number from which these payments will be transferred; and (4) the routing transit
number. Also check the appropriate box for the type of account — checking or savings.
0000
Tom and Mary Somebody
DEPOSIT TICKET
2
2
5432 Sameday Lane
Tom and Mary Somebody
20
Anywhere, NE 68000
5432 Sameday Lane
Pay to
Anywhere, NE 68000
20
DATE
the order of
$
1
Dollars
1
NET DEPOSIT
Our Financial Institution
Our Financial Institution
P.O. Box 000, Anywhere, NE 68000
P.O. Box 000, Anywhere, NE 68000
000000000 000 0000 0000
000000000 000 0000 0000
3
3
4
4
000000000 000 0000
000000000 000 0000
Attach a VOIDED check for this checking account or a VOIDED deposit slip for this savings account.
SECTION IV — AUTHORIZATION
This completed and signed form authorizes the Department to make automatic withdrawals from your checking or savings
account. An account owner, or other individuals authorized to make withdrawals, MUST sign this form.
PAYMENT DATE. The financial institution will transfer the amount of your payment automatically on the date specified in
Section II. However, because these transactions are not processed on Saturdays, Sundays, or financial institution holidays,
your actual payment date may be delayed to the next business day.
If this agreement will be used to pay more than one type of tax, or for more than one tax year, there will be occasions when
this will appear as two withdrawals on the same day. They will still total the amount of payment as specified in Section II.
If your financial institution notifies you that its ownership has changed, please contact the Department. A new Form 27D
may be needed.
If you make any additional payments, or have had refunds transferred to this balance, you must notify the agent
referenced on this form to discuss how this agreement will be affected.
IMPORTANT NOTICE: You will be assessed a $20 fee for any EFT payment from your account that is returned without
payment by your financial institution.
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