Form Rev-331a As - Authorization Agreement For Electronic Tax Payments Page 2

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Tax:
9
Check the appropriate block(s) to indicate the tax(es) you will be paying by EFT. Enter the account number for each tax type.
If you select the ACH debit option, the tax type(s) checked should fall under the bank account listed in Section 8 from which
the payment(s) will be drawn.
File (Box) Number
1.
Capital Stock/Foreign Franchise Tax
Loans Tax
(All 3 taxes reported on RCT-101)
–
Corporate Net Income Tax
File (Box) Number
2.
Utilities Gross Receipts Tax
–
File (Box) Number
3.
Gross Receipts Telecommunication Taxes for
–
Intrastate, Interstate, Mobile
File (Box) Number
4.
Public Utility Realty Tax
–
File (Box) Number
5.
Bank Shares Tax
Title Insurance and Trust Company Shares Tax
–
Bank Loans Tax
File (Box) Number
6.
Mutual Thrift Institutions Tax
–
File (Box) Number
7.
Insurance Premiums Tax
–
File (Box) Number
8.
Marine Insurance Premiums Tax
–
EIN
9.
Liquid Fuels and Fuels Tax
–
Account Number
10.
Motor Carriers Road Tax
–
Account Number
11.
IFTA - Motor Carriers
–
Account Number
12.
Malt Beverage Tax
Account Number
13.
Cigarette Stamp Agents
Account Number
14.
Pari-Mutuel
License Number
15.
Unstampable Little Cigar Tax
Authorized Signature Information:
10
I certify the information provided on this form is true and correct and authorize the PA Department of Revenue to use the
information herein in direct conjunction with the EFT program.
Print Name: Last
First
M.I.
Title
Date
Signature
Telephone Number
(
)
Make a copy of this completed Authorization Agreement for your records. You may fax your completed Authorization Agreement
to 717-787-0145, or mail it to the PA DEPARTMENT OF REVENUE, PO BOX 280908, HARRISBURG, PA 17128-0908.
For additional information on electronic filing visit or call 717-783-6277. Services for taxpayers
with special hearing and/or speaking needs: 1-800-447-3020 (TT only).

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