Direct Deposit/Tax E-Payment Auth

Direct Deposit / Electronic Payment Account Information

Direct Deposit/Electronic Tax Payment(s) Authorization

Select The Option Your Are Requesting

Direct Deposit Of Refund

Make Fed/State Electronic Tax Payment(s) By Bank Account Or Credit Card

This form is used for Dual Purposes: To provide account info for direct deposit of your refund or to make your tax liability payments electronically.

First & Last Name Of Person On Account *

Company Name (If A Business Account)

Type Of Bank Account *

Consumer Checking (Personal)

Business Checking

Savings/Other

Please Choose One

Bank Name

Bank Account Number

Bank Routing Number

Your Cell Phone Number *

Your Email Address *

Billing Address (Credit Cards & Bank Account Holders)

City

State/Province

Zip/Postal

If Paying A Tax Liability By Credit/Debit Card

Credit/Debit Card Type (Processing Fees Apply Check IRS/State Site For Details)

Visa

Master Card

American Express (higher rates usually apply)

Discover

Choose One Card Type To Pay A Fed/State Tax Liability By Card. If Multiple payment types please indiate details in notes section.

Name Of Card Holder

First

Last

Card Number

Exp Date (mm/yy)

CVV

3 or 4 digit code usually on back of card.

Digital Signature (Type Name For Digital Signature)

By signing this form you authorize Wagner Tax to set up Direct Deposit for your refund or submit your tax liability payment(s) from the bank account or credit/debit card information you provided above. Wagner Tax and its representatives cannot be held liable or responsible for NSF, processing errors, timed-out payment attempt(s), payment website malfunctions, or any other issue where payment does not go through or is returned. This includes Post payment notification of a returned or canceled payment. You also acknowledge that IRS/State agencies can switch a direct deposit to a paper check refund without notice at any time even though it was processed as a direct deposit initially. IRS/State taxing authorities usually provide a confirmation number and notice upon the completion of an electronic payment or direct deposit. There are however times when a payment or deposit is processed but the confirmation page fails to display or is interrupted when this happens there is no way for us to know if the payment was also interrupted. This is rare but full disclosure is necessary.

Notes: (Detail any special requests, including multi or partial payment/refund information.

If you intend to make partial payments or multiple payments with different cards or bank accounts or both--please detail that information here. If you need to submit multiple Payment Forms please do so and be clear with your notes.

If you are human, leave this field blank.

This form does not authorize Wagner Tax to use your bank account information for anything other than the direct deposit of your refund.