13929 Health Coverage Tax Credit (HCTC) Paper Check Request

Department of the Treasury – Internal Revenue Service
Form 13929

HEALTH COVERAGE TAX CREDIT (HCTC)

(October 2007)

PAPER CHECK REQUEST
Waiver of Electronic Funds Transfer (EFT) Transactions
(ACH Vendor/Miscellaneous Payment Enrollment Form)
Paper checks take approximately 7-10 business days for receipt, from date of disbursement.

CERTIFICATION (Check One)
The undersigned certifies receipt of HCTC payments to be a one-time occurrence, and does not expect to receive any more payments
this year.

The undersigned certifies that receiving payment at a financial institution by electronic means is not possible at this time. Send
payment by check. (Explanation Required)

Explanation:

Legal Business Name and Check Remittance Address:

EIN/TIN (Associated with
Legal Name):

Telephone Number:

ATTN:

Date:

Signature:

Title (Please Print):
Fax Completed Form To:

HCTC Finance & Accounting Center
ATTN: Your Finance & Accounting Representative
Fax Number: 1-800-675-9602

FOR INTERNAL REVENUE SERVICE USE ONLY
Input by

Vendor Code

Catalog Number 50984B

Date
The Internal Revenue Service is responsible for
maintaining copies of completed waivers, which
are subject to audit review as appropriate.

Form 13929 (10-2007)