Form 42a740-Epay - Electronic Payment Request Form - Department Of Revenue - 2016
ADVERTISEMENT
1
2DO NOT MAIL! RETAIN FOR YOUR RECORDS.
K
e
P
FORM EPAY
entucKy
lectronic
AyMent
2016
42A740-EPAY
r
F
eQueSt
orM
Department of Revenue
Submission ID: _______________________________________________________
Taxpayer Information
Primary Taxpayer Name: ______________________________________________
Primary Taxpayer SSN: ________________________________________________
Last, First, Middle Initial
Secondary Taxpayer Name: ____________________________________________
Secondary Taxpayer SSN: ______________________________________________
Last, First, Middle Initial
Street Address 1: __________________________________________________________________________________________________________________________________
Street Address 2: __________________________________________________________________________________________________________________________________
City: _________________________________________________
State: ___________________
Zip Code: ______________________________________________
Payment Information
Select the payment(s) that you would like to make and enter the financial institution information.
Payment of Tax Due ¨
Notice Number
___________________________ (if applicable)
1.
Enter additional tax due:
. 0 0
,
,
2.
Enter late file and/or late pay penalties and/or interest:
,
,
. 0 0
3.
Amount to be debited (Must equal sum of line 1 and line 2):
,
,
. 0 0
/
/
4.
Debit date:
Payment of Estimate Tax for Tax Year 2017 ¨
5.
Select payment date(s): ¨ April 18, 2017 ¨ June 15, 2017 ¨ September 15, 2017 ¨ January 16, 2018
6.
Amount to be debited per payment:
. 0 0
,
,
Financial Institution Information (Required)
7.
Routing transit number (RTN):
8.
Depositor account number (DAN):
9.
Select type of account: ¨ Savings ¨ Checking
10.
Will these funds come from an account located outside of the United States? ¨ Yes ¨ No
Declaration of Taxpayer
By submission of this form, I authorize the Kentucky Department of Revenue and its designated Financial Agent to initiate an ACH electronic funds withdrawal
entry to the financial institution account indicated above for payment of my state taxes owed and/or payment(s) of estimate tax, and the financial institution
to debit the entry to this account. This authorization is to remain in full force and effect until I notify the Kentucky Department of Revenue to terminate the
authorization. To revoke (cancel) a payment, I must contact the Kentucky Department of Revenue at (502) 564-4581 no later than 2 business days prior to the
payment (debit) date. I also authorize the financial institution involved in the processing of the electronic payment of taxes to receive confidential information
necessary to answer inquiries and resolve issues related to the payment.
Primary Taxpayer Signature (PIN): _________________________________________________________________________
Date: _________________________________
Secondary Taxpayer Signature (PIN): ______________________________________________________________________
Date: _________________________________
Declaration and Signature of Electronic Return Originator and Paid Preparer
I declare that I have verified the taxpayer’s proof of account and it agrees with the name shown on this form. The taxpayer will have signed this form before
I submit the payment request. I will give the taxpayer a copy of all forms and information to be filed with the Kentucky Department of Revenue, and have
followed all other requirements in Kentucky Publication KY-1345, Kentucky Handbook for Electronic Filers of Individual Income Tax Returns (Tax Year 2016).
ERO’s Signature: ______________________________________________________________ Also paid preparer ¨
Date: _______________________________________
ERO’s Name: ______________________________________________________________________________________________________________________________________
ERO Firm Name: ____________________________________________________________________________________
FEIN: _______________________________________
Street Address 1: __________________________________________________________________________________________________________________________________
Street Address 2: __________________________________________________________________________________________________________________________________
City: _________________________________________________
State: ___________________
Zip Code: ______________________________________________
Paid Preparer’s Signature: ________________________________________________________________________________
Date: _________________________________
Paid Preparer’s Name: _______________________________________________________________________________
ID #: ________________________________________
Paid Preparer’s Business Name: ______________________________________________________________________
FEIN: _______________________________________
Street Address 1: __________________________________________________________________________________________________________________________________
Street Address 2: __________________________________________________________________________________________________________________________________
City: _________________________________________________
State: ___________________
Zip Code: ______________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form R-1021 - Sales Tax Electronic Filing Payment Voucher - Louisiana Department Of Revenue - 2005
Financial
Form Dp-175 - Electronic Funds Transfer Ach Credit Registration For Business Tax Payments - New Hampshire Department Of Revenue Administration
Legal
Form R-540v - Individual Income Tax Electronic Filing Payment Voucher - Louisiana Department Of Revenue
Financial
Related Categories
Parent category: Financial