REV-692 FO (07-13)

                                Authorization to Honor Drafts/
     Bureau of Collections and  Automated Clearing House Debits for
     Taxpayer Services
                                Deferred Payment Plans

                                    See reverse for instructions.
START
Ü    To: Financial Institution Name

           Address (Main Office)

           City                                                                                                  State ZIP Code

           Routing Number

           Account Type                             Checking                                              Savings

           Account Number

     From:Account Owner (Individual or Company Name)

           Identification Number

           Owner’s Federal Employer Identification Number (FEIN)
           or Social Security Number: (SSN)  . . . . . . . . . . . . . . . . .

     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. 

     Date                                           SignaturePLEASE SIGNofAFTERAccountPRINTINGOwner(s)FORM

                      MM/DD/YYYY
     (If two signatures required on financial institution authorizations, both signatures are necessary here.)

                                                  PLEASE SIGN AFTER PRINTING FORM

                                Telephone Number, including Area( Code)

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                  Instructions

1.This form authorizes monthly payments for deferred payment plans through electronic
 funds transfer (EFT) from a taxpayer’s account to the PA Department of Revenue.

2. You must maintain a checking, savings or similar account at any financial institution that
 accepts ACH debits or drafts to be drawn on the account. If you do not have an account
 that provides checks, you may not use this form.

3.Complete two authorization forms as follows (Copies are not acceptable):

 • Enter the name of the financial institution and the address of its main office (not a
   branch).

 • Enter the routing number, the nine-digit number located at the bottom of a check. You
   are encouraged to contact your financial institution to verify the correct routing number.

 • Check the type of account.

 • Enter the account number.

 • If the account identified is a checking account, attach a voided check or a clear
   photocopy of a check. The routing number, account number and bank name must
   appear on the check.

 • Enter the name(s) of the account owner(s).

 • If the account owner is an individual, enter his/her Social Security number. Enter the
   federal employer identification number, if appropriate. This number may identify the tax
   account that will receive credit for payments.

 • Sign and date the form. The individual signing the form must be authorized to sign
   checks. If two signatures are required on a check, two authorized individuals must sign
   this form.

 • Provide a daytime telephone number where the PA Department of Revenue may contact
   you, should additional information be needed.

4. Return the original, signed authorization form and voided check (or clear photocopy) to the
 office within the PA Department of Revenue handling the tax account. Use the return
 envelope provided for your convenience or find the appropriate address on the Revenue
 website, www.revenue.state.pa.us.

5.Retain a copy of this form for your records.

6.Promptly notify the PA Department of Revenue of any changes to information provided on
 this authorization form, and submit a new authorization form when appropriate.

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