Attach a voided check or other account verification to this form.
First payment date: the date cannot be the 29-31st days of the month.
Routing: your account number and 9-digit routing transit number are on the bottom edge of your check, or call your financial institution for assistance.
Authorization: it remains in effect until cancelled by the signer in writing, or until the amount is fully paid.
Cancellation: the signer agrees that it may take up to two weeks to process a cancellation or amendment request.
| Question | Answer |
|---|---|
| Form Name | Form A-771a |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 27 |
| Avg. time to fill out | 5 min |
| Edition | 9-18 |
| Issuing agency | Wisconsin Department of Revenue |
| Where to send | Email DORCompliance@wisconsin.gov, or mail to Compliance Bureau, Wisconsin Department of Revenue, PO Box 8901, Madison, WI 53708-8901 |
| Who signs | The person authorizing the Electronic Funds Transfer from their account |
| Other names | A-771a, A771a, A 771a, A-771A, Form A-771a, Wisconsin A-771a, Electronic Funds Transfer Authorization |
| Official source | Form A-771a (Rev 9-18), Wisconsin Department of Revenue |
Form A 771A isn’t the one you’re looking for?