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                                                                                    Wisconsin Department of Revenue
Electronic Funds Transfer Authorization                                                                            2135 Rimrock Rd
                                                                                                                    PO Box 8901
This form must be completed and signed by the person                                             Madison WI  53708-8901
authorizing the Electronic Funds Transfer from their account.
                                                                                                  Phone: (608) 266-7879
                                                                                                     Fax: (608) 224-5790
Click mouse in box below and enter Taxpayer Name.  Tab throughout rest of form.
                                                                                             DORCompliance@wisconsin.gov
Taxpayer name(s)

Address                                                   City                    State      Zip code

Social security number or EIN                             Phone number
                                                          ( )

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 financial 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Amount to be Withdrawn   $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

                   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 financial institution 
identified above in accordance with the payment plan agreement between the debtor identified above and DOR. This authorization 
remains in effect 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 financial institution identified above changes, I agree to submit an 
updated EFT Authorization Agreement to DOR. If a debit (withdrawal) cannot be completed because of insufficient funds, I understand 
and agree that I or the debtor identified above may be subject to fees charged by DOR or the financial institution.

AUTHORIZED SIGNATURE
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 effect as if 
a paper original had been delivered.

                 Authorized Signer Name (please print)                         Authorized Signer Name (please print)

                              Signature                                             Signature

                              Date                                                           Date
A-771a (R. 9-18)                                                                                                         revenue.wi.gov