Form A 771A PDF Details

The A 771A form plays a crucial role for individuals or entities looking to authorize electronic funds transfer (EFT) to the Wisconsin Department of Revenue. This process facilitates the seamless withdrawal of funds directly from the account holder's bank account, removing the need for manual processing and expediting the payment of taxes or other dues to the department. Located at 2135 Rimrock Rd, PO Box 8901, Madison, WI 53708-8901, the department uses this form to ensure accurate, timely, and secure transactions. Completing and signing the form is mandatory for the initiator, requiring information such as the taxpayer's name, address, Social Security Number or Employer Identification Number (EIN), and detailed banking information including the name of the financial institution, account number, and routing transit number. It offers options for the transfer to be made from either a checking or savings account. The form allows taxpayers to specify the monthly date—either the 5th, 15th, or 25th—for the funds withdrawal, aligning with the terms of an installment agreement between the taxpayer and the Department of Revenue. To avoid processing delays, the form advises attaching a voided check or other form of account verification, and clearly outlines the terms for changing or cancelling the authorization. This transparent process is designed to minimize errors and ensure that both parties have a clear understanding of the withdrawal amounts and dates, ultimately ensuring compliance and facilitating efficient revenue collection.

QuestionAnswer
Form NameForm A 771A
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
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ELECTRONIC FUNDS TRANSFER AUTHORIZATION

This form MUST be completed and signed by the person authorizing the Electronic Funds Transfer from their account.

Wisconsin Department of Revenue 2135 Rimrock Rd PO Box 8901

Madison WI 53708-8901

Phone: (608) 266-7879 Fax: (608) 261-8978

delnqtax@dor.state.wi.us

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.

Amount to be withdrawn $

The day the Electronic Funds Transfers are to be made (check one)

5th

15th

25th

of each month.

* * ATTACH A VOIDED CHECK OR OTHER ACCOUNT VERIFICATION TO THIS FORM * *

The payment amount, specified in the Installment Agreement between the taxpayer (identified above) and the Department of Revenue, will be the authorized amount of the monthly Electronic Funds Transfer. The date that the monthly Electronic Funds Transfers are to be made on is indicated above. If this date falls on a day which is not available for transfer, the authorized day of transfer will be the next available day. This authorization will remain in effect until cancellation by me, in writing to the Department of Revenue, or until the amount due, as specified in the Installment Agreement, is fully paid. It may take up to two weeks to process my request to cancel my authorization.

If a withdrawal cannot be completed because funds are unavailable in my account, I will be subject to any overdraft fees that the Department of Revenue or my financial institution may charge.

AUTHORIZED BY:

Authorized Signer Name (please print)

 

Authorized Signer Name (please print)

 

 

 

Signature

 

Signature

 

 

 

Date

 

Date

A-771a (N. 7-02)

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This document will involve specific details; to guarantee consistency, take the time to take into account the suggestions further down:

1. The Form A 771A usually requires certain details to be typed in. Ensure the next fields are filled out:

Form A 771A writing process explained (portion 1)

2. Just after the first array of fields is completed, go to type in the applicable information in all these: Your account number and digit, Amount to be withdrawn, The day the Electronic Funds, of each month, Attach a voided check or other, The payment amount specified in, If a withdrawal cannot be, AUTHORIZED BY, Authorized Signer Name please print, Authorized Signer Name please print, Signature, and Signature.

Part # 2 in submitting Form A 771A

It's very easy to make errors when filling out your Authorized Signer Name please print, for that reason make sure you take another look before you'll finalize the form.

Step 3: When you have reread the details in the file's blanks, press "Done" to complete your document creation. After registering a7-day free trial account with us, it will be possible to download Form A 771A or email it immediately. The form will also be readily available from your personal account page with all your changes. FormsPal is committed to the confidentiality of all our users; we make sure all personal data coming through our editor continues to be confidential.

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