Form Wt 8655 - Withholding Tax Payroll Service Company Authorization And Release
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WT 8655
Prescribed 7/12
Withholding Tax Payroll Service Company Authorization and Release
.
Reporting agent agrees to provide authorization to the Ohio Department of Taxation within 24 hours of request
1. Taxpayer Information. Taxpayer must sign and date this form on line 6.
Taxpayer name
Employer identifi cation number (EIN)
Address
Social Security number
City, state and ZIP code
Daytime telephone number
2. Reporting Agent Information
Name
Employer identifi cation number (EIN)
Address
Telephone number
City, state and ZIP code
Fax number
3. State Authorization
The taxpayer hereby grants the reporting agent with limited power of attorney with the authority to sign and fi le employment tax returns
and make deposits electronically, on magnetic media or on paper with the Ohio Department of Taxation. The reporting agent is also
hereby authorized to receive notices, correspondence and transcripts from the Ohio Department of Taxation, resolve matters pertaining
to these deposits and fi lings, and to request and receive deposit frequency data and any other information related to the taxpayer’s
state individual income and school district income tax withholding returns and deposits.
This authorization shall include all Ohio Department of Taxation state individual income and school district income tax withholding
forms and shall commence with the tax period of
/
and shall remain in effect through all subsequent periods until either
revoked by the taxpayer or terminated by the reporting agent. Unless the taxpayer is required to fi le or deposit electronically, the report-
ing agent will, at its discretion, fi le and make deposits on the taxpayer’s behalf either electronically, on magnetic media or on paper.
4. Retention/Revocation of Authorization
This authorization automatically revokes all earlier authorizations on fi le with the Ohio Department of Taxation for the same years or
periods covered by this document. If you do not want to revoke a prior authorization, check this box:
You MUST attach a copy of any tax information authorization that you want to remain in effect.
5. Acknowledgement of Responsiblity
I understand that this agreement does not relieve me, as the taxpayer, of the responsibility to ensure that all tax returns are fi led and
that all deposits and payments are made.
6. Signature of or for Taxpayer
I hereby certify that the Ohio Department of Taxation is authorized to release any and all Ohio withholding tax information in accordance
with section 3 above that is in the possession of the department concerning the undersigned taxpayer to the reporting agent specifi ed
by this authorization and release. Further, I hereby relieve the Ohio tax commissioner, the Ohio Department of Taxation or any agent
or employee thereof from any liability whatsoever for releasing such information.
I certify under penalties of perjury that I am the taxpayer identifi ed below or have the authority to execute this withholding tax informa-
tion authorization and release on behalf of the taxpayer.
If this withholding tax information authorization and release is not signed, it will be returned.
Print name
Signature
Title
Date
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Parent category: Financial