Form 27D Fillable Payment and Authorization Agreement for Electronic Funds Transfer (EFT) of Tax Payments (7/2014)
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

000000000 000 0000 0000 22 Individual 21 Withholding 24 Corporation 01 Sales and Use Tax Other: Checking Savings DEPOSIT TICKET I/we hereby authorize the Nebraska Department of Revenue (Department) upon my/our initiation only to accept Automated Clearing Read instructions on reverse side Section II Payment Proposal Set Up EFT Account Change EFT Account Information Terminate EFT Authorization Supersedes 7 242 1996 Rev 4 2013 000 0000 000000000 5432 Sameday Lane 7 242 1996 Rev 7 2014 A voided check must be attached for checking accounts payments acceptable form of agreement the Department will allow for delinquent taxes account An account owner or other individuals authorized to make withdrawals MUST sign this form account based on your authorization Be sure the Department has this agreement at least ten days prior to your starting date address must be completed by every taxpayer agreement Any overpayment that might otherwise be refunded will be applied to this liability until the liability is paid in full amount of delinquent Nebraska and local tax in the tax categories listed above for up to one year after the expiration of this agreement Anywhere NE 68000 Approved assigned one If you do not have a federal ID number enter your Social Security number Attach a voided check for this checking account or a voided deposit slip for this savings account Authorized Signature Authorized Signature (Spouse) Authorized Signature Nebraska Department of Revenue Business Name And Location Address (If Applicable) charge See instructions on reverse side for important information Check the appropriate boxes for the delinquent tax programs this agreement will resolve Enter the total amount due the City State Zip Code Complete this section and list the sources and amount of any income you or this business receives Please list this income in Complete your Nebraska Business ID Number if you have been assigned one Enter the federal ID number if you have been Delinquent Tax Programs: Department can collect against a tax delinquency without filing a lien against your property for one year after the expiration Dollars E Mail Address Enter the amount you will pay on a regular basis These payments if accepted will be automatically deducted from your Enter: (1) the name and address of the financial institution from which you want these payments deducted; (2) the exact name financial institution information as deemed necessary to enable payment by EFT I/we acknowledge that a lien may be filed for the Financial Institution Name and Address Routing Transit Number first installment Send this agreement to: Nebraska Department of Revenue PO Box 94609 Lincoln Nebraska 68509 4609 for Electronic Funds Transfer (EFT) of Tax Payments for these payments from the Department House (ACH) transactions as payment on this account I/we also authorize the Department to release any of the above taxpayer and I/we authorize and direct the Nebraska Department of Revenue to initiate a withdrawal from my/our account described as follows: I/we propose to make payments as follows: starting If a withdrawal cannot be completed because funds are unavailable in the account I/we will be subject to any overdraft fees that the financial institution may If the Department does not accept this proposal a new proposal and a more detailed financial statement will be sent to you If this agreement is approved payments will be made using EFT All state taxes and returns will be filed and paid in a timely manner during the terms of this If this agreement will be used to pay more than one type of tax or for more than one tax year there will be occasions when If you are in bankruptcy do not file this form Instead speak with someone in our Bankruptcy Unit by calling 402 595 2069 If you make any additional payments or have had refunds transferred to this balance you must notify the agent If your financial institution notifies you that its ownership has changed please contact the Department A new Form 27D Important Notice: You will be assessed a $20 fee for any EFT payment that is returned without payment by your financial institution (including situations where the taxpayer has provided the Department with incorrect account information) The Instructions Mail this form with a voided check or deposit slip to: may be needed monthly figures Attach additional sheets if necessary Name of Spouse s Employer Length of Employment Date Paid Gross Monthly Wages Net Monthly Wages Name of Your Employer Length of Employment Date Paid Gross Monthly Wages Net Monthly Wages Names on Account Account Number Type of Account Nebraska Department of Revenue PO Box 94609 Lincoln NE 68509 4609 Nebraska ID Number Federal ID Number Daytime Phone Home Phone NET DEPOSIT number Also check the appropriate box for the type of account checking or savings of this payment agreement if the delinquency is not satisfied or 402 595 2070 Other income (include child support alimony interest etc ) Specify sources Amount Our Fiancial Institution P O Box 000 Anywhere NE 68000 Pay to payment agreement with the Department or by anyone who wishes to change or terminate an existing agreement Payment and Authorization Agreement Payment Date The financial institution will transfer the amount of your payment automatically on the date specified in payments through an electronic funds transfer (EFT) from your financial institution With certain exceptions this is the only Payments will be made: Weekly Bi Weekly 1st & 15th Monthly Last Day of Month periods of delinquency and the date interest has been computed through Refer to your most recent Balance Due Notice Purpose of This Form: Purpose The Payment and Authorization Agreement Form 27D should be used when entering into a payment agreement referenced on this form to discuss how this agreement will be affected Section I Income Section II However because these transactions are not processed on Saturdays Sundays or financial institution holidays Section II Payment Proposal Section III Financial Institution Account Information Section IV Authorization shown on your account; (3) the account number from which these payments will be transferred; and (4) the routing transit Social Security Number Spouse s Social Security Number Nebraska Department of Revenue Agent Name/Phone Number Specific Instructions Business name and location address should be completed if this agreement involves any tax other Street Address Street or Other Mailing Address Taxpayer name (name of corporation partnership; if sole proprietorship or individual income tax enter your full name) and Taxpayer Name and Address termination The Department reserves the right to terminate this agreement at its sole discretion than individual income tax Enter the name and address under which you do business the order of This authorization is to remain in full force and effect until the Department has received written notification from the taxpayer of its This authorization will remain in effect until cancellation in writing to the Nebraska Department of Revenue This completed and signed form authorizes the Department to make automatic withdrawals from your checking or savings this will appear as two withdrawals on the same day They will still total the amount of payment specified in Section II Title Title Tom and Mary Somebody Total Liability Tax Periods of Delinquency Date Interest Computed Through Total Monthly Net Income When and Where to File This agreement must be received by the Department at least ten days prior to the due date of the Who Must File This payment and authorization agreement must be completed by any taxpayer who wishes to enter into a with the Nebraska Department of Revenue (Department) Your signature authorizes the Department to obtain agreed upon your actual payment date may be delayed to the next business day