ContractPayment and Authorization Agreement for Electronic Funds Transfer (Eft) of Tax Payments • August 19th, 2016
Name Name Street Address Street or Other Mailing Address City State Zip Code City State Zip Code Nebraska ID Number Federal ID Number Daytime Phone Home Phone
ContractPayment and Authorization Agreement for Electronic Funds Transfer (Eft) of Tax Payments • April 24th, 2008
Payment and Authorization Agreementfor Electronic Funds Transfer (EFT) of Tax Payments• Read instructions on reverse side FORM27D BUSINESS NAME AND LOCATION ADDRESS (if applicable) TAXPAYER’S NAME AND ADDRESS Name Name Street Address Street or Other Mailing Address City State Zip Code City State Zip Code Nebraska Identification Number Federal Identification Number Business Phone( ) Home Phone( ) Social Security Number Spouse’s Social Security Number Revenue Agent Name/Phone Number
