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Illinois Department of Revenue

EFT1 Authorization Agreement for Certain Electronic Payments

Read this information rst!CompletethisormONLYiyou

wanttouseACHcredit,thepay-by-phonedebitmethod,orthedirectfledebitmethodtopayamountsowedtotheIllinoisDepartment

Revenue,or arechangingpreviouslysubmittedinormationaboutoneothemethodsopaymentlistedabove.

Note: Formosttaxes,electronicpaymentscanbemadeeasilyonourwebsiteusingWebPayattax.illinois.gov.If you use WebPay, do ncomplete this form.

Step 1: Complete the following information

1Checkthepaymentmethodyouwishtouse(orwishtoupdate). 2 Checkthereasonyouarecompletingthisorm.

ACHcredit Initialsetup(CheckthisboxandskiptoStep2.)

Pay-by-phonedebit Changetopreviouslysubmittedinormation

Directfledebit(orsales,telecommunications,tobacco, 3 Iachange,writetheeectivedate. ____/____/________ liquor,andcigarette)

4 Explainthechange:__________________________________

Step 2: Identify yourself

5 _________________________________________________ 7 ___ ___ ___ ___ ___ ___ ___ ___ ___ Taxpayersname Federalemployeridentifcationnumber(FEIN)

6 _________________________________________________ 8 ___ ___ ___ ___ ___ ___ ___ ___ ___ Address SocialSecuritynumber(SSN) _________________________________________________ C ityStateZIP

Step 3: Complete designated agent or contact person information

9 _________________________________________________ 11(_____)_________________(_____)________________ Designatedagentsorcontactpersonsname TelephoneFax 10_________________________________________________ 12 _______________________________________________ Address Emailaddress _________________________________________________ 13 _______________________________________________ City State ZIP

Signatureauthorization(authorizedofcerodesignatedagentorcontactperson

Step 4: Check the taxes for which you wish to authorize these payments

EFT-1ront(R-6/11)

Illinois income taxes:

Individualincometax _______________________ IllinoisAccountIDnumber

Withholdingincometax _______________________ IllinoisAccountIDnumber

Businessincometax _______________________ IllinoisAccountIDnumber

Sales taxes: SalesandUseTax _______________________ IllinoisAccountIDnumber

ChicagoSotDrinkTax _______________________ IllinoisAccountIDnumber

CountyMotorFuelTax _______________________ IllinoisAccountIDnumber

MPEAFoodandBeverageTax _______________________ IllinoisAccountIDnumber

PrepaidSalesTax(motoruel) _______________________ IllinoisAccountIDnumber

AutomobileRentingTax _______________________ IllinoisAccountIDnumber

Excise taxes:

ElectricityDist.andInvestedCapital___________________ IllinoisAccountIDnumber

GasRevenueandGasUseTax ____________________ IllinoisAccountIDnumber

ElectricityExciseTax _____________________ IllinoisAccountIDnumber

TelecommunicationsTax _____________________ IllinoisAccountIDnumber

TelecomInrastructureMaint.Fee____________________ IllinoisAccountIDnumber

TobaccoProductsTax_____________________ IllinoisAccountIDnumber

HotelTax_____________________ IllinoisAccountIDnumber

LiquorTax_____________________ IllinoisAccountIDnumber

LiquorAirlineTax_____________________ IllinoisAccountIDnumber

Use your mouse or Tab key to move through the fields. Use your mouse or space bar to enable check boxes.

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Step 5: If using the paybyphone debit or direct le debit method, complete the following14 _________________________________________________ 17 Checkone: Business or Individual/Consumer

Financialinstitutionsname

15 _________________________________________________ 18 Checkone: Checkingor Savings Nameonaccount 16 _________________________________________________ 19 ___ ___ ___ ___ ___ ___ ___ ___ ___ Accountnumber Routingtransitnumber

Step 6: Sign and complete

Thesignatureothetaxpayer,authorizedofcer,orpartnerisrequired,aswellasthetitleanddate(eveniyouareusingadesignatedage

Underpenaltiesoperjury,IstatethatIhaveexaminedthisormandtothebestomyknowledgeitistrue,correct,andcomplete.TheIllinoisDepartmentoRevenueisauthorizedtousethisinormationinaccordancewiththeDepartmentoRevenueLawotheCivilAdministrativeCodeoIllinoisandallapplicabIllinoistaxacts.Thisagreementshallremaininorceuntilthedepartmentreceiveswrittennotifcationromthetaxpayer.

_________________________________________________ _______________________ ____/____/________ Signatureotaxpayer,authorizedofcer,orpartner Title Date

Step 7: Mail or fax completed form Mailto: ELECTRONIC FUNDS TRANSFER DIVISION Faxnumber:217 5248282

ILLINOIS DEPARTMENT OF REVENUEPO BOX 19015SPRINGFIELD IL 627949015

Form EFT1 Instructions

What is the WebPay method?TheWebPaymethodisanelectronictranserthatyouauthorize

allowingthedepartmenttoinitiateadebittransactiononthefnancial

accountthatyouprovide.WebPayisavailableonourwebsiteto

makemosttaxpayments.Thismethodnormallydoesnotrequire

submissionothisorm.Gotoourwebsiteattax.illinois.gov.

What is the direct le debit method?Forsales,telecommunications,tobaccoandliquortaxesonly:The

directfledebitmethodisanelectronictransertoususingsotware

youdeveloporpurchase.

For cigarette stamp purchasers: Youarerequiredtomarkthe

directfledebitboxinStep1,Line1iyouwillbebuyingcigarette

taxstamps.

What is ACH credit?AnAutomatedClearingHouse(ACH)creditisanelectronictranser

thatyouauthorizetellingyourfnancialinstitutiontowithdraw

Specic Instructions

romyouraccountordepositintoouraccountusingyourfnancial

institutionssystem.Werecommendthatyoucontactyourbank

todeterminewhatACHservicestheyoerbeoreyouchoosethis

option.

What is the paybyphone debit method?

Thepay-by-phonemethodisanelectronictranserthatoccurswheyouauthorizeouragenttotranserundsromyouraccountonthe

datethatyouselect.Iyouchoosethepay-by-phonedebitoption

youmustcompleteaseparateFormEFT-1oreachaccountrom

whichyouwillmakepayments.

What if I need help?Iyouneedassistance,youmaycallusweekdaysbetween8a.m.

and5p.m.at217 7826257.Youalsomayvisitourwebsiteat

tax.illinois.govorwritetousat

ELECTRONIC FUNDS TRANSFER DIVISION

ILLINOIS DEPARTMENT OF REVENUE

PO BOX 19015

SPRINGFIELD IL 627949015

General Information

Step 1: Complete the following informationCheckthepaymentmethodyouwishtouseandwhetherthisisan

initialregistrationoriyouarechanginginormationyoupreviously

provided.

Attachadditionalsheetsinecessary.

Step 3: Complete designated agent or contactperson informationIadesignatedagentwillbetranserringpayments,completeStep3.

IthedesignatedagentiscompletingFormEFT-1onbehaloa

taxpayer,thetaxpayermustprovideasignatureinStep6,unlessa

signedFormIL-2848-Eiskeptinthedesignatedagentsbooksand

records.

Ithepay-by-phoneoptionwillbeusedandthebankaccoun

isthedesignatedagents,anauthorizedofcerotheagent

mustsignonStep3,Line13,toauthorizeustodebitthataccount.

Acontactpersonshouldbethepersonwhowillbeinitiatingandm

ingthepaymenttranser.Includethetelephonenumber,axnumber

andemailaddress.

EFT-1back(R-6/11)

ThisormisauthorizedbytheDepartmentoRevenueLawotheCivilAdministrativeCode.Disclosureothisinormationisrequired.Failuretocomplymayresultinapenalty.ThisormhasbeenapprovedbytheFormsManagementCenter. IL-492-3255

Taxpayersname

_________________________________________________

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