Tax Payment Authorization Form

TAX PAYMENT AUTHORIZATION FORM

Taxpayer Name:   Taxpayer Identification Number (SSN/TIN):

Remitter / Payor Information

Scope of Authorization

By signing below, Taxpayer authorizes Remitter to withhold, transfer and remit payments for the taxes indicated on behalf of the Taxpayer to the appropriate taxing authorities in accordance with the terms set forth herein. This authorization applies only to payments specified under "Payment Purpose" below and does not alter Taxpayer's filing obligations or liabilities.

Federal income tax    State income tax    Payroll / Withholding tax    Estimated tax payments    Other:

Payment Amount and Schedule

One-time    Weekly    Monthly    Quarterly    Other:

Requested Start Date:   Requested End Date (if applicable):

Payment Method

Select preferred payment method and provide account details. Remitter shall rely on the information below to initiate transfers. Taxpayer agrees to notify Remitter immediately of any change in account information or authority to debit the account.

ACH Debit (Bank transfer)    Credit / Debit Card    Check    Other:

Representations, Warranties & Consent

Taxpayer represents and warrants that the information provided on this form is true, accurate and complete and that Taxpayer is authorized to provide the banking or card account information and to authorize debits from such accounts. Taxpayer consents to Remitter initiating automated debits and/or card transactions as described above and understands that such transactions may be subject to the rules of the originating financial institution and applicable law.

Taxpayer acknowledges that Remitter will rely on the information provided and that Remitter may stop or reject any payment instruction if Remitter determines that it lacks authority or if the instruction conflicts with law or internal policies. Taxpayer remains liable for payment of any tax obligations, penalties or interest due to insufficient or incorrect withholding or remittance.

Revocation: This authorization remains in effect until revoked in writing by the Taxpayer and delivered to the Remitter at the address provided above. Revocation will be effective only after Remitter has had a reasonable opportunity to act on the revocation and will not affect transactions already initiated.

Liability and Indemnification

Taxpayer agrees to indemnify, defend and hold harmless Remitter, its officers, employees and agents from and against any claims, losses, damages or expenses resulting from inaccurate information provided by Taxpayer, Taxpayer's failure to timely notify Remitter of changes, or Taxpayer's failure to comply with applicable tax laws. Remitter's liability for any error will be limited to correction of the error and reimbursement of any proven direct loss caused by the error.

Additional Instructions / Notes

Acknowledgment and Certification

By signing below, Taxpayer certifies under penalty of perjury that the information provided is accurate, that Taxpayer has legal authority to authorize payments from the account described, and that Taxpayer authorizes Remitter to initiate payments in accordance with this form. Taxpayer acknowledges receipt of a copy of this authorization upon request.

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