A-771a (R. 9-18) revenue.wi.gov
Wisconsin Department of Revenue
2135 Rimrock Rd
PO Box 8901
Madison WI 53708-8901
Phone: (608) 266-7879
Fax: (608) 224-5790
DORCompliance@wisconsin.gov
Electronic Funds Transfer Authorization
This form must be completed and signed by the person
authorizing the Electronic Funds Transfer from their account.
Address City State Zip code
Taxpayer name(s)
Social security number or EIN Phone number
( )
**
Attach a voided check or other account verification to this form
**
I authorize the Department of Revenue (DOR) to initiate debit entries (withdrawals) to the bank account at the nancial institution
identied above in accordance with the payment plan agreement between the debtor identied above and DOR. This authorization
remains in eect until cancelled by me in writing, or until the amount is fully paid. I understand and agree that it may take up to two
weeks to process a cancellation or amendment request. If the nancial institution identied above changes, I agree to submit an
updated EFT Authorization Agreement to DOR. If a debit (withdrawal) cannot be completed because of insucient funds, I understand
and agree that I or the debtor identied above may be subject to fees charged by DOR or the nancial institution.
I authorize and direct the State of Wisconsin, Department of Revenue to initiate withdrawal from the account described
as follows:
Name of Financial Institution
Account Name
Account Number (check one) Checking Savings
Routing Transit Number
Your account number and 9-digit routing transit number are on the bottom edge of your check,
or call your nancial institution for assistance
Payment Frequency (check one) Monthly Bi-Weekly Weekly
Amount to be Withdrawn $
First Payment / Withdrawal Date Date cannot be the 29‑31st days of the month
AUTHORIZED SIGNATURE
Authorized Signer Name (please print) Authorized Signer Name (please print)
Signature Signature
Date Date
/ /
By signing below, I agree that I have read and agree to the terms and conditions stated above. I also certify that I am authorized by
all necessary and appropriate action to execute this authorization. The parties acknowledge and agree that a handwritten signature,
delivered by facsimile, PDF, email or other similar electronic means, is legal and binding and has the same full force and eect as if
a paper original had been delivered.
Click mouse in box below and enter Taxpayer Name. Tab throughout rest of form.
