Form 27d - Payment And Authorization Agreement For Electronic Funds Transfer (Eft) Of Tax Payments

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Payment and Authorization Agreement

FORM

27D

nebraska

for Electronic Funds Transfer (EFT) of Tax Payments

RESET FORM

department

of revenue

• Read instructions on reverse side

BUSINESS NAME AND LOCATION ADDRESS (if applicable)

TAXPAYER’S NAME AND ADDRESS

Name

Street Address

Street or Other Mailing Address

City

State

Zip Code

City

State

Zip Code

Nebraska Identiﬁcation Number

Federal Identiﬁcation Number

Business Phone

Home Phone

Social Security Number

Spouse’s Social Security Number

Revenue Agent Name/Phone Number

Delinquent Tax Program(s):

22 — Individual

21 — Withholding

24 — Corporation

01 — Sales and Use Tax

Other:

Purpose of This Form:

Total Liability

Tax Period(s) of Delinquency

Date Interest Computed Through

Change EFT Account Information

Set Up EFT Account

Terminate EFT Authorization

SECTION I — Income

Name of Your Employer

Length of Employment

Date(s) Paid

Gross Monthly Wages

Net Monthly Wages

Name of Spouse’s Employer

Length of Employment

Date(s) Paid

Gross Monthly Wages

Net Monthly Wages

Other income (include child support, alimony, interest, etc.). Specify source.

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

If this agreement is approved, payments will be made using Electronic Funds Transfer. All state taxes and returns will be ﬁled and paid timely during the terms

of this agreement. Any refunds that might otherwise be due will be applied to this liability until the liability is satisﬁed.

SECTION III — Bank Account Information

I/we authorize and direct the State of Nebraska, Department of Revenue, to initiate a withdrawal from my/our account, described as follows:

Financial Institution Name and Address

Routing Transit Number

Name(s) on Account

Account Number

Type of Account

Checking

Savings

ATTACH VOIDED CHECK FOR CHECKING ACCOUNT OR DEPOSIT SLIP FOR SAVINGS ACCOUNT TO THE SPACE ON THE LEFT SIDE OF THIS FORM.

This authorization will remain in effect until cancellation by me/us, in writing, to the Nebraska Department of Revenue.

If a withdrawal cannot be completed because funds are unavailable in my/our account, I/we will be subject to any overdraft fees that my/our ﬁnancial institution

may charge. See instructions on reverse side for important information.

SECTION IV — Authorization

I/we hereby authorize the Nebraska Department of Revenue, upon my/our initiation only, to accept Automated Clearing House

transactions as payment on my/our account. I/we also authorize the Nebraska Department of Revenue to release any of the above

taxpayer and ﬁnancial institution information, as deemed necessary, to enable payment by electronic funds transfer. This authorization

is to remain in full force and effect until the Nebraska Department of Revenue has received written notiﬁcation from the taxpayer of its

termination. The Nebraska Department of Revenue reserves the right to terminate this agreement at its sole discretion.

sign

here

Authorized Signature

Date

Title