(ET+) 07-19 
                                                 AUTHORIZATION TO HONOR       OFFICIAL USE ONLY
                        REV-692 
                                                             DRAFTS/AUTOMATED 
                                          CLEARING HOUSE DEBITS FOR 
                                                 DEFERRED PAYMENT PLANS

      SECTION I FINANCIAL INSTITUTION INFORMATION
START  Name of Financial Institution 
Ü
       Street Address (Main Office)

       City                                                                              State ZIP Code

       Routing Number          Account Type                                    Account Number
                                          Checking           Saving

      SECTION II ACCOUNT OWNER INFORMATION
       Account Owner (Individual or Company Name)

       Identification Number                                                   Owner’s FEIN or SSN

      SECTION III CERTIFICATION
      I (we) request and authorize the financial institution named above to charge to the above-identified account drafts/ACH debits payable 
      to the PA Department of Revenue, Harrisburg, PA 17128. 
      I (we) agree that the authenticity of a payment order from the PA Department of Revenue need not be verified. I (we) further agree that 
      a payment order from the PA Department of Revenue is authorized until revoked, in writing, to both the financial institution and the PA 
      Department of Revenue.  
      If the PA Department of Revenue cannot deduct the monthly payment from my (our) account due to insufficient funds or account closure, 
      my (our) payment agreement will be cancelled and a penalty will be imposed. I understand that if verbal authorization has already been 
      granted to the department, the ACH debits will begin, regardless of completion and return of this form.

       Signature of Account Owner                                              Phone Number DateMM/DD/YYYY
                              SIGN AFTER PRINTING
       Signature of Second Account Owner (if necessary) Phone Number Date
                              SIGN AFTER PRINTING

      Reset Entire Form       TOP OF PAGE                                     NEXT PAGE PRINT

No text to extract.

                                                                 Pennsylvania Department of Revenue 

                                                                 Instructions for REV-692 
                                               Authorization to Honor Drafts/Automated Clearing House  
REV-692 IN (ET+) 07-19                                                    Debits for Deferred Payment Plans
                                                               • If the account owner is an individual, enter his/her 
            GENERAL INFORMATION                                  Social Security number. Enter the federal employer 
This form authorizes monthly payments for deferred               identification number, if appropriate. This number may 
payment plans through electronic funds transfer (EFT) from       identify the tax account that will receive credit for 
a taxpayer’s account to the PA Department of Revenue.            payments. 

You must maintain a checking, savings or similar account at                     SECTION III
any financial institution that accepts ACH debits or drafts to                                                        
be drawn on the account. If you do not have an account that    CERTIFICATION 
provides checks, you may not use this form.                    • Sign and date the form. The individual signing the 
                                                                 form must be authorized to sign checks. If two 
            LINE INSTRUCTIONS                                    signatures are required on a check, two authorized 
                                                                 individuals must sign this form. 
                       SECTION I
                                                               • Provide a daytime telephone number where the PA 
FINANCIAL INSTITUTION INFORMATION                                Department of Revenue may contact you, should 
                                                                 additional information be needed. 
Complete two authorization forms as follows (Copies are 
not acceptable): 
                                                                                 HOW TO FILE
•  Enter the name of the financial institution and the                                                                
   address of its main office (not a branch).                  Return the original, signed authorization form and voided 
                                                               check (or clear photocopy) to the office within the PA 
•  Enter the routing number, the nine-digit number 
                                                               Department of Revenue handling the tax account. Use the 
   located at the bottom of a check. You are encouraged 
                                                               return envelope provided for your convenience or find the 
   to contact your financial institution to verify the correct 
                                                               appropriate address on the Revenue website, 
   routing number. 
                                                               www.revenue.pa.gov. 
•  Check the type of account. 
                                                                 IMPORTANT: Retain a copy of this form for your 
•  Enter the account number.                                     records. 
•  If the account identified is a checking account, attach 
                                                               Promptly notify the PA Department of Revenue of any 
   a voided check or a clear photocopy of a check. The 
                                                               changes to information provided on this authorization form, 
   routing number, account number and bank name 
                                                               and submit a new authorization form when appropriate. 
   must appear on the check. 

                       SECTION II
                                                        
ACCOUNT OWNER INFORMATION 
•  Enter the name(s) of the account owner(s). 

www.revenue.pa.gov                                                                                   REV-6921

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