Form 2159 - Payroll Deduction Agreement

Download a blank fillable Form 2159 - Payroll Deduction Agreement in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 2159 - Payroll Deduction Agreement with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Department of the Treasury — Internal Revenue Service
2159
Form
Payroll Deduction Agreement
(Rev. April 2003)
(See Instructions on the back of this page.)
TO:
Regarding:
(Employer name and address)
(Taxpayer name and address)
Contact Person's Name
Telephone
Social security or employer identification number
(Include area code)
(Taxpayer)
(Spouse)
Your telephone number
EMPLOYER—
. The taxpayer identified
(Include area code)
See the instructions on the back of Part 2
(Home)
(Work or business)
above on the right named you as an employer. Please read and sign the
following statement to agree to withhold amount
from the taxpayer's
(s)
For assistance, call:
1-800-829-0115
or
(Business)
wages or salary to apply to taxes owed.
(employee's)
1-800-829-8374
, or
(Individual – Self-Employed/Business Owners)
I agree to participate in this payroll deduction agreement and will withhold the
1-800-829-0922
(Individuals – Wage Earners)
amount shown below from each wage or salary payment due this employee.
I will send the money to the Internal Revenue Service every:
Or write:
Campus
(Check one box.)
(City, State, and ZIP Code)
WEEK
TWO WEEKS
MONTH
OTHER
(Specify.)
Financial Institution
(s) (Name and address)
Signed:
Title:
Date:
Kinds of taxes
Tax Periods
(Form numbers)
Amount owed as of
$
, plus all penalties and
interest provided by law.
I am paid every:
:
(Check one)
WEEK
TWO WEEKS
MONTH
OTHER
(Specify.)
I agree to have $
deducted from my wage or salary payment beginning
until the total liability is paid in full. l also agree and
authorize this deduction to be increased or decreased as follows:
Date of increase
Amount of Increase
New installment payment amount
(or decrease)
(or decrease)
Terms of this agreement—By completing and submitting this agreement, you
agree to the following terms:
(the taxpayer)
You will make each payment so that we
receive it by the
authority to deduct this fee from your first payment(s) after the
(IRS)
monthly due date stated on the front of this form.
agreement is reinstated.
If you cannot make
We will apply all payments on this agreement in the best interests
a scheduled payment, contact us immediately.
This agreement is based on your current financial condition. We
of the United States.
may modify or terminate the agreement if our information shows
We can terminate your installment agreement if:
that your ability to pay has significantly changed. You must provide
You do not make monthly installment payments as agreed.
updated financial information when requested.
You do not pay any other federal tax debt when due.
While this agreement is in effect, you must file all federal tax
You do not provide financial information when requested.
returns and pay any
taxes you owe on time.
If we terminate your agreement, we may collect the entire amount
(federal)
We will apply your federal tax refunds or overpayments
to
you owe by levy on your income, bank accounts or other assets, or
(if any)
the amount you owe until it is fully paid.
by seizing your property.
You must pay a $43 user fee, which we have authority to deduct
We may terminate this agreement at any time if we find that
from your first payment
.
collection of the tax is in jeopardy.
(s)
If you default on your installment agreement, you must pay a $24
This agreement may require managerial approval. We'll notify you
reinstatement fee if we reinstate the agreement. We have the
when we approve or don't approve the agreement.
Additional Terms
Note: Internal Revenue Service employees
(To be completed by IRS)
may contact third parties in order to process
and maintain this agreement.
Your signature
Title
Date
(If Corporate Officer or Partner)
Spouse's signature
Date
(If a joint liability)
Agreement examined or approved by
Date
(Signature, title, function)
AGREEMENT LOCATOR NUMBER:
A NOTICE OF FEDERAL TAX LIEN
(Check one box below.)
Input Review Suppress Indicator: “1” (u
nless specific balance due IA)
HAS ALREADY BEEN FILED
Check box if specific balance due IA; input Review Suppress Indicator “6”
WILL BE FILED IMMEDIATELY
Agreement Review Cycle:
Earliest CSED
Check box if pre-assessed modules included
WILL BE FILED WHEN TAX IS ASSESSED
Originator's ID:
Originator Code:
MAY BE FILED IF THIS AGREEMENT DEFAULTS
Name:
Title:
Part 1
Acknowledgement Copy
2159
Form
(Rev. 4-2003)
(Return to IRS)
Catalog No. 21475H

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Financial
Go
Page of 3