Tax Form 9779 With Instructions (2007) (Page 2 of 2) in pdf

For side 2 please fill in

Employer Identification Number (EIN)

(continued)

EIN:

Payment Information

8. Payment Method. Choose the

8. Payment Method

payment method(s) by placing an “X” in

EFTPS (by Internet and/or phone): check here if you will instruct EFTPS to transfer payment from your account.

the box(es). The options available

are: EFTPS using the Internet or

EFTPS (through a Financial Institution): check here if you will instruct your financial institution to forward the payment to EFTPS.

phone and EFTPS through a Financial

You must check with your financial institution to determine if they are capable of providing this service.

Institution. Both EFTPS input methods

NOTE: If you will only be using EFTPS through your Financial Institution as a payment method, skip to item #23.

are interchangeable: Internet and phone.

✍

Note: For EFTPS (using the Internet or phone), complete the additional information required about your financial institution. Enrollment will automatically

enroll you for EFTPS through a Financial Institution as well as Same-Day Payment.

For EFTPS (through a Financial Institution) , you initiate a tax payment through a financial institution. You must contact your financial institution to insure the

institution is capable of making an EFTPS payment through the Automated Clearing House (ACH) or a Same-Day Payment method. If you enroll for EFTPS through

a Financial Institution or Same-Day Payment, you may also enroll for EFTPS using the Internet or phone by providing the financial institution information

requested on items 19 through 23.

Tax Form Payment Amount Limits

(EFTPS using the Internet or phone only)

9-18. Optional Tax Form Payment

10.

11.

Amount Limits (For EFTPS using the

720

940

941

Internet or phone only)

12.

13.

14.

This section is optional. You may set

amount limits for each tax type to

943

945

990C

prevent an overpayment. The system will

15.

16.

17.

compare your payment amount against

your stated limit and provide a warning if

990PF

990T

1042

you exceed the limit. You may override

18.

the warning if you wish.

1120

(19 through 24 must be completed if

EFTPS using the Internet or phone will

Financial Institution Information

(to be completed if EFTPS using the Internet or phone will be used)

be used)

19. RTN:

20. Account Number:

21. Type:

19. RTN. This is the nine-digit number

associated with your financial institution.

Checking

You may contact your financial institution

Savings

to verify this number.

22. State:

ZIP Code:

20. Account Number. Enter the number

of the account you will use to pay your

taxes.

21. Type. Please mark one box to indicate

whether the account is a checking or

Authorization

savings account.

22. State and ZIP Code. Use the two-

23. For both payment methods: Please read the following Authorization Agreement:

character letter abbreviation for the state

your financial institution is located in and

I (as defined as the taxpayer whose signature is below) hereby authorize the contact person (listed in item #4 of this form) and the financial institutions involved

in the processing of my Electronic Federal Tax Payment System (EFTPS) payments to receive confidential information necessary to effect enrollment in EFTPS,

indicate ZIP Code.

electronic payment of taxes, and answer inquiries and resolve issues related to enrollment and payments. This information includes, but is not limited to, passwords,

payment instructions, taxpayer name and identifying number, and payment transaction details. If signed by a corporate officer, partner, or fiduciary on behalf of

23. Authorization. This section authorizes

the taxpayer, I certify that I have the authority to execute this authorization on behalf of the taxpayer. This authorization is to remain in full force and effect until

a Financial Agent of the U.S. Treasury to

the designated Financial Agents of the U.S. Treasury have received notification from me of termination in such time and in such manner to afford a reasonable

initiate tax payments from the account(s)

opportunity to act on it.

you designate.

24. Taxpayer Signature. The taxpayer

Only EFTPS using the Internet or phone: Please read the following Authorization Agreement:

must sign this section to authorize

By completing the information in boxes 19-22 and signing below, I hereby authorize designated Financial Agents of the U.S. Treasury to initiate EFTPS debit

participation in EFTPS. If there is no

entries to the financial institution account indicated above, for payment of Federal taxes owed to the IRS upon request by taxpayer or his/her representative, using

signature, a form will be returned.

the Electronic Federal Tax Payment System (EFTPS). I further authorize the financial institution named above to debit such entries to the financial institution

This section also provides authorization

account indicated above. All debits initiated by the U.S. Treasury designated Financial Agents pursuant to this authorization shall be made under U.S. Treasury

to share the information provided with

regulations. This authorization is to remain in full force and effect until the designated Financial Agents of the U.S. Treasury have received written notification

your financial institution, required for the

from me of termination in such time and in such manner as to afford a reasonable opportunity to act on it.

processing of the Electronic Federal Tax

Payment System.

24. Taxpayer Signature

If signed by a corporate officer, partner,

Date

or fiduciary on behalf of the taxpayer,

Taxpayer Signature

the signer certifies that they have the

authority to execute this authorization on

Title

behalf of the taxpayer.

Print Name

Remember to sign and mail your

enrollment form to the address on

Paperwork Reduction Act Notice: In accordance with the Paperwork Reduction Act of 1995, we ask for the information in the Electronic Federal Tax Payment System (EFTPS) Enrollment Form in order to carry out the requirements of 26 United

reverse side.

States Code 6001, 6011, and 6109. You are not required to provide information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its

instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103. This information is

used by the Internal Revenue Service to assure that payment(s) are properly credited to the appropriate account(s). Your response is mandatory if you are required by regulations to use Electronic Funds Transfer to make your Federal Tax Deposits.

The time needed to provide this information will vary depending on individual circumstances. The estimated average time is ten minutes. If you have comments concerning the accuracy of this time estimate or suggestions for reducing this

burden, we would be happy to hear from you. You can write to the IRS Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, Washington, DC 20224. Please do not send the enrollment form to this address.

The Privacy Act of 1974 requires that when we ask individuals for information about themselves, we state our legal right to ask for the information, why we are asking for the information, and how it will be used. We must also tell you what could

happen if we do not receive all or part of it, and whether your response is voluntary, required to obtain a benefit, or mandatory. Our legal right to ask for information is 5 U.S.C. 301 and Internal Revenue Code sections 6001, 6011, 6012, and

applicable regulations. The information will be used to enroll you in the Electronic Federal Tax Payment System (EFTPS). The information may not be disclosed except as provided by section 6103 of the Internal Revenue Code. We may give the

information to the Department of Justice and to other Federal agencies, as provided by law. We may also give it to cities, states, the District of Columbia, and U.S. commonwealths or possessions to carry out their laws. We may give it to foreign

governments because of tax treaties they have with the United States. Your response is mandatory if you are required by regulations to use electronic funds transfer to make your deposits. If you are not required by regulations to use electronic

funds transfer, your response is voluntary. If you do not provide all or part of the information, you may not be eligible to participate in the EFTPS. If you are required to use electronic funds transfer by regulation, you may be subject to penalties. If

you are not required to use electronic funds transfer to pay taxes owed, you need to pay the taxes due by another method.

U.S. Government Printing Office:

Cat. No.: 21816U

Form 9779 (2/07)