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Illinois Department of Revenue
CPP-1-AACH Debit Payment Authorization for Installment Payment Plan
Step 1: Identify yourself (and spouse, if applicable) B If business debt, identify your business or organization
A ___ ___ ___ - ___ ___ - ___ ___ ___ ___ ___ ___ - ___ ___ ___ ___ ___ ___ ___
Your Social Security number Federal employer identification number (FEIN)
___ ___ ___ - ___ ___ - ___ ___ ___ ___ ___ ___ ___ ___ - ___ ___ ___ ___
Your spouse’s Social Security number Illinois account ID
__________________________________________________
Your first name and middle initial Last name Legal business name: ________________________________
_________________________________________________________________ Doing-business-as (DBA), assumed, or trade name, if different
Your spouse’s first name and middle initial Last name from the legal business name on the line above:
_________________________________________________________________
Street address - No PO Box number Apartment or suite number __________________________________________________
_________________________________________________________________ __________________________________________________
City State ZIP Business mailing address
_________________________________________________________________ __________________________________________________
Your email address City State ZIP
(_____)______________ (_____)______________ __________________________________________
Your home phone number Your work phone number Name of person responsible for remitting payments
(_____)______________ (_____)______________ (_____)______________ (_____)______________
Your mobile phone number Your spouse’s phone number Phone number Alternate phone number
Step 2: Describe your ACH payment frequency
1 Check one of the following options to describe how often you will make payments.
One payment per month One payment per week One payment every other week
Date of month ___ ___ Day of week _______________ Day of week _______________
Step 3: Provide your financial institution and account information
6 ______________________________________________________
Financial institution’s name
____________________________________________________________________________________________________________________
Mailing address City State ZIP
____________________________________________________________________________________________________________________
Name(s) on the account (list all names)
Routing number ___ ___ ___ ___ ___ ___ ___ ___ ___ Checking or Savings
Find your routing number at the bottom of your check (for checking accounts) or contact your financial institution for the routing number (for savings accounts).
Account number ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Check this box to authorize ACH debit payments from this account.
Step 4: Read the statement and sign below
I agree to, and understand, that (1) the Illinois Department of Revenue (IDOR) is authorized to use the information on this form to make withdrawals
(ACH debits) at the frequency I selected in Line 5 and from the account listed on Line 6 in accordance with the Department of Revenue Law of the Civil
Administrative Code of Illinois and all applicable Illinois tax acts, and that this authorization remains in effect until the debt is paid or I notify IDOR in writing
to cancel ;(2) IDOR may request additional information about my financial condition and I may be required to pay a higher amount than the payment plan
described above; (3) IDOR has the discretion to file a lien at any time, including, but not limited to, when IDOR determines there is a risk of non-
payment; (4) IDOR may contact me about this payment plan at any address and phone number listed in Step 1 (this includes electronic communication
by email or text); and (5) if I do not remit the scheduled payment, file all required returns, and pay all taxes when due, IDOR may cancel my installment
payment plan, my entire unpaid balance will become due immediately, and IDOR may take enforcement action, including levy of my bank account or wages.
Under penalties of perjury, I state that I have examined this form and, to the best of my knowledge, it is true, correct, and complete.
______________________________________________________________________ __ __ / __ __ / __ __ __ __
Your signature or authorized officer (if officer, write title) Month, day, year
Please fax your completed form to us at 217 785-2635 or mail it to:
INSTALLMENT CONTRACT UNIT
ILLINOIS DEPARTMENT OF REVENUE Reset Print
PO BOX 19035
SPRINGFIELD IL 62794-9035
Department use only
_________________________________ __ / __ __ / __ __ __ __ ______________________________ __ __ / __ __ / __ __ __ __
Approved by assignee Date approved by assignee Approved by supervisor Date approved by supervisor
This form is authorized as outlined under the tax or fee Act imposing the tax or fee for which this form is filed. Disclosure of this Printed by the authority of the
CPP-1-A (R-03/19) information is REQUIRED. Failure to provide information may result in this form not being processed and may result in a penalty. state of Illinois - web only, 1