Form A-771a at a glance
What it is: Electronic Funds Transfer Authorization: you authorize and direct the State of Wisconsin, Department of Revenue to initiate withdrawal from the account described.
Who signs: This form must be completed and signed by the person authorizing the Electronic Funds Transfer from their account.
What to bring and attach to Form A-771a
Attach a voided check or other account verification to this form.
A filled-in Form A-771a example: a monthly payment from a checking account
How to fill out Form A-771a, box by box
Taxpayer name(s), Address and Social security number or EIN
Enter the Taxpayer name(s), the Address, City, State and Zip code, the Social security number or EIN and the Phone number.
Account Number, Checking or Savings and Routing Transit Number
Enter the Name of Financial Institution, the Account Name, the Account Number and the Routing Transit Number, and check one: Checking or Savings.
Your account number and 9-digit routing transit number are on the bottom edge of your check, or call your financial institution for assistance.
Payment Frequency, Amount to be Withdrawn and First Payment / Withdrawal Date
Check one Payment Frequency: Monthly, Bi-Weekly or Weekly.
Enter the Amount to be Withdrawn after the $.
Enter the First Payment / Withdrawal Date; the date cannot be the 29-31st days of the month.
AUTHORIZED SIGNATURE
Under AUTHORIZED SIGNATURE, print the Authorized Signer Name, then add the Signature and the Date.
By signing, you agree that you have read and agree to the terms and conditions stated on the form, and a handwritten signature, delivered by facsimile, PDF, email or other similar electronic means, is legal and binding and has the same full force and effect as if a paper original had been delivered.
More rules for Form A-771a
This authorization remains in effect until cancelled by me in writing, or until the amount is fully paid.
I understand and agree that it may take up to two weeks to process a cancellation or amendment request.
If the financial institution identified on the form changes, I agree to submit an updated EFT Authorization Agreement to DOR.
If a debit (withdrawal) cannot be completed because of insufficient funds, I understand and agree that I or the debtor identified on the form may be subject to fees charged by DOR or the financial institution.
Common questions about Form A-771a
Where do I file it?
Submit completed forms by: Email to: DORCompliance@wisconsin.gov , or Mail to: Compliance Bureau Wisconsin Department of Revenue PO Box 8901 Madison, WI 53708-8901[2]
Sources
[1] Form A-771a (R. 9-18), Electronic Funds Transfer Authorization, Wisconsin Department of Revenue (the Official source link on this page).
[2] revenue.wi.gov, submission_method (revenue.wi.gov). Accessed November 7, 2026.