dor-electronic-funds-transfer-authorizatio-form.pdf
PDF 74 KB Posted
- Solicitation number
- BD-25-1067-MCD01-MCD01-113447
- Issued by
- Suffolk County, Massachusetts
About this file
The document is an Electronic Funds Transfer (EFT) Authorization Form from the Massachusetts Department of Revenue (DOR), designed to enable taxpayers to set up automatic tax payments through their bank accounts. The form allows individuals to enroll in the DOR's EFT program by providing their banking details, with options to choose payment frequency (weekly, bi-weekly, or monthly) and specify the installment amount. Taxpayers can complete the enrollment online through MassTaxConnect or by mailing the physical form to the DOR Collections Bureau in Boston.
The form requires detailed taxpayer information, including identification numbers, bank account details (routing and account numbers), and signatures. It provides instructions for attaching bank verification documentation such as a voided check or pre-printed savings deposit slip. Taxpayers can use this form to establish a new payment agreement or modify an existing one, with the authorization remaining in effect until written notification of termination is provided to both the DOR and the bank. The form can be submitted electronically or by mail, with contact information provided for the Collections Bureau at 617-887-6400 for any questions or assistance.
View the file
Other files
Show all 11
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Visit MassTaxConnect at mass.gov/masstaxconnect to enroll in the Department of Revenue's (DOR's) EFT program for your payment agreement. Once enrolled in EFT, your payments will be deducted automatically from your bank account and submitted to DOR for the duration of the payment agreement. If you are unable to activate your EFT enrollment in MassTaxConnect, complete and mail this form to Massachusetts DOR, Collections Bureau, PO Box 7021, Boston, MA 02204. Call the Collections Bureau at 617-887-6400 with any questions.
Step 1. Complete Requested Information
Reason for submission:
New enrollment n Change enrollment n
Taxpayer name Taxpayer Identification number
Spouse name / Responsible person name Spouse SSN / Responsible person SSN
Name as appears on check/bank statement SSN or FID (if different)
I (we) hereby authorize DOR to initiate debit entries from my (our) checking/savings account indicated below and the Depository named below to debit the same from such account.
Depository name (Your bank name)
Transit/ ABA number (“Routing #”) Account number
Indicate below the type of bank account (checking or savings), installment amount, frequency (weekly, bi-weekly or monthly) and date you would like payments debited from your account:
n Checking account n Savings account
Payment plan installment amount n Weekly ____________________ n Bi-weekly ____________________ n Monthly ____________________ First date to debit First date to debit First date to debit
Note: This authority is to remain in full force and effect until DOR and the Depository have received written notification from me (or either of us) of its termination in such time and in such manner as to afford DOR and the Depository a reasonable opportunity to act on it.
Name(s) on account (print) ID numbers on account
Date Signature Spouse's signature
Step 2. Attach Depository Information:
Enclose a copy of your voided check or pre-printed savings deposit slip with banking numbers printed on the bottom. Or, enclose a copy of a letter from your depository that verifies your banking information (i.e., name, account number, routing number).
Electronic Funds Transfer Authorization Form
Massachusetts Department of Revenue
| Taxpayer name: |
| Taxpayer Identification number: |
| Spouse name Responsible person name: |
| Spouse SSN Responsible person SSN: |
| Name as appears on checkbank statement: |
| SSN or FID if different: |
| Depository name Your bank name: |
| Transit ABA number Routing: |
| Account number: |
| Payment plan installment amount: |
| First date to debit: |
| First date to debit_2: |
| First date to debit_3: |
| Names on account print: |
| ID numbers on account: |
| Date: |
| new_enroll: Off |
| change_enroll: Off |
| checking: Off |
| savings: Off |
| weekly: Off |
| biweekly: Off |
| monthly: Off |
| Sig1: |
| Sig2: |
File details come from the government source that posted it. Updated .