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Tion This form must be completed and signed by the person authorizing the Electronic Funds Transfer from their account. Click mouse in box below and enter Taxpayer Name. Tab throughout rest of form. Taxpayer Name(s) Address City Social Security Number or EIN Phone Number ( State Zip Code ) I authorize and direct the State of Wisconsin, Department of Revenue to initiate withdrawal from the account described as follows: Name of Financial Institution Account Name (check one) Account Num.

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