Form 13287 - Bank Payment Problem Identification printable pdf download

Department of the Treasury – Internal Revenue Service

13287

Form

Bank Payment Problem Identification

(December 2009)

Section I.

Information Supplied by Bank

Part 1: Taxpayer Information

(For completion by bank)

1. Taxpayer Identification Number

2. Multiple TINs

3. Form(s) Payment Intended For

4. Tax Period(s) Payment Intended For

(TIN)

(if known)

(DO NOT enter the EIN of the taxpayer's bank.)

(if known)

Yes

(See attached list)

Part 2: Bank Information

(For completion by bank)

5. Name of Bank

6. Federal Employer Identification Number

(Enter complete legal name of responsible bank)

of Bank

(FEIN)

7. Bank Branch Street Address

8. Branch Number of Bank Where Problem

Occurred

9. City, State, ZIP Code

10. American Banking Association

Number

(ABA)

12. Telephone Number

11. Bank Contact Name and Title

(Please print)

(

)

13. FAX Number

(

)

14. Number of Payments Delayed 15. Payment / Combined Payments Amount

16. Method of Payment

(“x” proper box)

ACH debit

ACH credit

Coupon

Fed wire

17. Date T/P Requested

18. Date Payment

19. Number of Days

20. Date IRS was

21. Mode of Contact

(“x” proper box)

Payment

Payment Late

(explain in item 26)

Transmitted

Contacted

Phone

FAX

Letter

22. Problem Involved Multiple Payments

23. Deposit Made More than 48 Hours After

24. IRS Contacted within 48 Hours of Problem

Problem Discovered

Discovery

Yes

(See attached list.)

(Explain in Item 25.)

25. Explanation

(Items 23 and 24)

26. Brief explanation why payment could not be processed as taxpayer requested

By signing below, I understand that the financial institution listed above will accept responsibility for the payment

delay.

(s)

27. Name

28. Title

(Please print)

Signature

Authorization of

Bank Official

29. Signature

30. Date

INFORMATION SUPPLIED BY INTERNAL REVENUE SERVICE

Section II.

Part 3: IRS Information

(For completion by IRS)

31. History

32. Resolution

33. Name of Taxpayer

34. Taxpayer

35. Date Bank's Completed Form

36. Method of Taxpayer Contact

Correspondence Date

13287 received at IRS

(“x” proper box)

Phone

FAX

Letter

37. TC 971

38. Payment Date

39. Intended Payment Date

40. Additional Action(s) for Adjustment(s)

to Account

(TC 181, ADX 48/24/34)

Action Code 30 ___

41. IRS Contact Name (Please print)

42. IRS Contact Employee

43. IRS Contact Phone Number

Number

(

)

44. IDRS Input Date

45. Master File Projected 23C

46. Date Information FAXd to Federal

(mm/dd/yyyy)

Posting Date

Reserve Board

(FRB)

13287

Catalog No. 34294M

Form

(Rev. 12-2009)

Form 13287 - Bank Payment Problem Identification

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