REV-692 FO (3-03)
Commonwealth of Pennsylvania
PA Dept. of Revenue
Bureau of Collections and
Authorization to Honor Drafts/
Automated Clearing House Debits for
Deferred Payment Plans
To: Bank Name (The “Bank”)
Bank Address (Main Office)
City State ZIP Code
Bank Routing Number
Bank Account Type Checking Savings
Bank Account Number
From: Account Owner (Individual or Company Name)
(EIN or SSN) of Owner
I (we) request and authorize the Bank named above to pay and charge to the above authorized account
for drafts/ACH. Debits drawn on the account listed above by and payable to the order of 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 author-
ized until revoked, in writing, to both the Bank and the PA Department of Revenue.
If the PA Department of Revenue cannot deduct the monthly payment for my deferred payment plan
from my (our) account due to insufficient funds, or the account is closed, my (our) payment agree-
ment will be cancelled and a penalty will be imposed.
Date Signature of Account Owner(s)
(If 2 signatures required, both signatures are necessary)
Telephone Number and Area Code ( )
SEE INSTRUCTIONS ON REVERSE
1. This form is used to authorize monthly payments for deferred payment plans through the
electronic funds transfer of monies from the taxpayer’s bank account to the PA Department
of Revenue’s bank account.
2. You must maintain a checking, savings or similar account at any bank that will accept
Automated Clearing House (ACH) Debits or Drafts drawn on the account. A current
personal or business checking or savings account may be used.
3. Complete two original copies of the authorization form as follows:
• Enter the name of the bank and the address of the main office (not the branch bank).
• Enter the bank account number and bank routing number from which to draft/debit
funds on a monthly basis. The bank routing number is the nine-digit number located
at the bottom left of a check. You may contact your bank to verify the correct bank
• Check the type of bank account from which to draft/debit funds.
• Attach a voided check or a clear photocopy of a check from the bank account identified.
The bank routing number, bank account number and bank name must be noted on the
• Enter the name of the owner(s) of the bank account.
• Enter the Social Security Number if the account owner is an individual or the Employer
Identification Number if appropriate. This number may identify the tax account that will
receive credit for making the payment.
• 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
the authorization form.
• Provide a daytime telephone number where the PA Department of Revenue can contact
you should additional information be needed.
4. Provide one copy of the signed authorization form to the bank. If dealing with a branch
bank, instruct the branch bank to forward the form to the appropriate area within its main
office. The authorization form is usually maintained in the bank’s Authorization or
Electronic Funds Transfer Department.
5. Return one copy of the signed authorization form and a voided check (or clear photocopy)
to the PA Department of Revenue office which is handling the tax account. Use the return
envelope provided for your convenience. The Department’s Web site may be accessed at
www.revenue.state.pa.us and then click on the “Contact Us” link to locate the Revenue
office address. You must retain a copy of this form for your records.
6. You must promptly notify the PA Department of Revenue office of any changes to
information found on this authorization form and execute a new authorization form
following the instructions noted above.