Maine Revenue Services
Individual Income Tax
Electronic Funds Withdrawal Affirmation

AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS WITHDRAWAL

Taxpayer Name 	     			SSN	  		Date	     

I hereby authorize Maine Revenue Services to initiate an electronic withdrawal (ACH debit) in the amount of

$    		from my

•	Checking
•	Savings

account and financial institution named below.

Bank Name:  
Nine-digit routing number:  
Bank account number: 

Date of electronic withdrawal:

The electronic withdrawal will be initiated on the date indicated above.  Expect the amount to be withdrawn no later than 3 business days after that date.

Do not mail this form to Maine Revenue Services.  Retain this form with your tax records.