Kentucky Electronic Payment Request Form

Electronic Payment Request Form
Form EPAY
FORM

EPAY

Kentucky Electronic PAYMENT
REQUEST FORM

Commonwealth of Kentucky
Department of Revenue

2023

DO NOT MAIL! RETAIN FOR YOUR RECORDS.

Submission ID:___________________________________________________

Taxpayer Information
Primary Taxpayer Name:___________________________________________ 	

Primary Taxpayer SSN:_____________________________________________

Secondary Taxpayer Name:_________________________________________ 	

Secondary Taxpayer SSN:__________________________________________

Last, First, Middle Initial
Last, First, Middle Initial

Street Address 1:_______________________________________________________________________________________________________________________
Street Address 2:_______________________________________________________________________________________________________________________
City:_____________________________________________ 	State:__________________ 	

Zip Code:___________________________________________

Payment Information
Select the payment(s) that you would like to make and enter the financial institution information.
Payment of Tax Due ¨

Notice Number 	 _ _______________________ 	 (if applicable)

,

,

1	

Enter additional tax due:

2	

Enter late file and/or late pay penalties and/or interest:

3	

Amount to be debited (Must equal sum of line 1 and line 2):

4	

Debit date:

 /    

.	0	 0
,

,
,

/

,

.	0	 0
.	0	 0

Payment of Estimate Tax for Tax Year 2024 ¨
5	

Select payment date(s):  ¨ April 15, 2024  ¨ June 17, 2024  ¨ September 16, 2024  ¨ January 15, 2025

6	

Amount to be debited per payment:

,

,

.	0	 0

Financial Institution Information (Required)
7	

Routing transit number (RTN):

8	

Depositor account number (DAN):

9	

Select type of account:  ¨ Savings  ¨ Checking

10	

Will these funds come from an account located outside of the United States? ¨ Yes  ¨ No

Declaration of Taxpayer
By submission of this form, I authorize the Kentucky Department of Revenue and its designated Financial Agent to initiate an ACH electronic funds withdrawal entry to
the financial institution account indicated above for payment of my state taxes owed and/or payment(s) of estimate tax, and the financial institution to debit the entry to
this account. This authorization is to remain in full force and effect until I notify the Kentucky Department of Revenue to terminate the authorization. To revoke (cancel)
a payment, I must contact the Kentucky Department of Revenue at (502) 564-4581 no later than 2 business days prior to the payment (debit) date. I also authorize the
financial institution involved in the processing of the electronic payment of taxes to receive confidential information necessary to answer inquiries and resolve issues
related to the payment.
Primary Taxpayer Signature (PIN):___________________________________________________________________ 	Date:______________________________
Secondary Taxpayer Signature (PIN):________________________________________________________________ 	Date:______________________________

Declaration and Signature of Electronic Return Originator and Paid Preparer
I declare that I have verified the taxpayer’s proof of account and it agrees with the name shown on this form. The taxpayer will have signed this form before I submit the
payment request. I will give the taxpayer a copy of all forms and information to be filed with the Kentucky Department of Revenue, and have followed all other requirements
in Kentucky Publication KY-1345, Kentucky Handbook for Electronic Filers of Income Tax Returns (Tax Year 2023).
ERO’s Signature:_________________________________________________________ 	 Also paid preparer  ¨	Date:____________________________________
ERO’s Name:__________________________________________________________________________________________________________________________
ERO Firm Name:____________________________________________________________________________ 	FEIN:____________________________________
Street Address 1:_______________________________________________________________________________________________________________________
Street Address 2:_______________________________________________________________________________________________________________________
City:_____________________________________________ 	State:__________________ 	

Zip Code:___________________________________________

Paid Preparer’s Signature:_________________________________________________________________________ 	Date:______________________________
Paid Preparer’s Name:_______________________________________________________________________ 	

ID #:____________________________________

Paid Preparer’s Business Name:_______________________________________________________________ 	FEIN:____________________________________
Street Address 1:_______________________________________________________________________________________________________________________
Street Address 2:_______________________________________________________________________________________________________________________
City:_____________________________________________ 	State:__________________ 	

42A740-EPAY (10-23)	

Zip Code:___________________________________________

Page 1 of 2

FORM EPAY (2023)

Purpose of Form
The purpose of this form is to authorize
the Kentucky Department of Revenue and
its designated Financial Agent to initiate
an ACH electronic funds withdrawal to
the financial institution account indicated
by the taxpayer for payment of taxes
and estimated tax other than at the time
of filing the individual income tax return.
If the request is being made at the time
of filing the individual income tax return,
the Form 8879-K, Kentucky Individual
Income Tax Declaration For Electronic
Filing should be completed.
Completing the Form
Submission Identification Number
(SID)
Enter the 20-digit Submission
Identification Number (SID) assigned
by the software.
Do not mail the form. Complete the form
and retain for a period of three years. If
the taxpayer is using an ERO, it is the
responsibility of the ERO to obtain the
signature of the taxpayer(s), retain the
form and provide the taxpayer with a
copy of the signed form.
Name, Social Security Number and
Address
Enter your last name, first name, middle
initial, social security number and mailing
address.
Payment Information
Select the type of payment(s) you would
like to make.
Payment of Tax Due
Include Notice Number, if applicable.
Line 1—Enter the amount of tax you
are paying.
Line 2—Enter the total amount of
penalties and interest you are paying.
Line 3—Enter the amount to be debited
for the payment of tax due plus penalties
and interest. This should be the sum of
line 1 and line 2.
Line 4—Enter the date you want the
payment to be withdrawn from your
account. Actual withdrawal of funds may
42A740-EPAY (10-23)

Instructions for Form EPAY

	
Page 2 of 2

Kentucky Electronic Payment Request Form
be later than the scheduled date. Please
allow up to two weeks for processing.
Payment of Estimated Tax for Tax
Year 2024

blank or incomplete forms.
Declaration and Signature of
Electronic Return Originator and
Paid Preparer

Entries in this section allow you to
schedule withdrawals from the account
specified in the financial institution
information for estimated tax for the
upcoming tax year. You can choose
to make one to four equal payments
depending upon the debit dates selected.

This section must be completed and
signed by the ERO and paid preparer.

Line 5—Select the date(s) you want
the payment to be withdrawn from your
account. Up to four equal payments may
be selected by choosing the appropriate
boxes. Actual withdrawal of funds may
be later than the scheduled date. Please
allow two weeks for processing.

A paid preparer who is not the ERO
must complete, sign and date the paid
preparer information.

Line 6—Enter the amount that will be
withdrawn from your account on each of
the dates selected on line 5.
Financial Institution Information
This section is required in order to
process the payment.
Line 7—Enter your financial institution’s
routing number. The routing number must
be 9-digits and begin with 01 through 12
or 21 through 32.
Line 8—Enter the account you wish
the payment to be withdrawn from. The
account number can be up to 17-digits
in length.
Line 9—Select the type of account the
payment will be withdrawn from.
Line 10—Indicate whether your account
is located outside the United States. Due
to federal electronic banking regulations,
you must answer the question if you are
paying the amount you owe via direct
debit. Requests will not be processed for
accounts located outside the U.S.
Declaration of Taxpayer
The taxpayer must sign and date the
Form EPAY prior to transmitting the
electronic payment request to verify and
confirm that the information is correct
and that the taxpayer agrees to the
withdrawal.
EROs and tax preparers are prohibited
from obtaining taxpayer signatures on

If the ERO is also the paid preparer, the
ERO must check the paid preparer box,
but is not required to complete or sign
the paid preparer information.