Fillable Form 2159 - Payroll Deduction Agreement (Page 6 of 6) in pdf

Form 2159 - Payroll Deduction Agreement Page 6

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INSTRUCTIONS TO TAXPAYER

If not already completed by an IRS employee, please fill in the information in the spaces

provided on the front of this form for the following items:

• Your employer’s name and address

• Your name(s) (plus spouse’s name if the amount owed is for a joint return) and

current address.

• Your social security number or employer identification number. (Use the number

that appears on the notice(s) you received.) Also, enter the last four digits of your

spouse’s social security number if this is a joint liability.

• Your home and work telephone number(s)

• The complete name and address of your financial institution(s)

• The kind of taxes you owe (form numbers) and the tax periods

• The amount you owe as of the date you spoke to IRS

• When you are paid

• The amount you agreed to have deducted from your pay when you spoke to IRS

• The date the deduction is to begin

• The amount of any increase or decrease in the deduction amount, if you agreed

to this with IRS; otherwise, leave BLANK

After you complete, sign (along with your spouse if this is a joint liability), and date this

agreement form, give it to your participating employer. If you received the form by mail,

please give the employer a copy of the letter that came with it.

Your employer should mark the payment frequency on the form and sign it. Then, your

employer should return the parts of the form which were requested on your letter or

return Part 1 of the form to the address shown in the “For assistance” box on the front of

the form.

If you need assistance, please call the appropriate telephone number below or write IRS

at the address shown on the form. However, if you received this agreement by mail,

please call the telephone number on the letter that came with it or write IRS at the

address shown on the letter.

For assistance, call: 1-800-829-0115 (Business), or

1-800-829-8374 (Individual – Self-Employed/Business Owners), or

1-800-829-0922 (Individuals – Wage Earners)

Note: This agreement will not affect your liability (if any) for backup withholding under

Public Law 98-67, the Interest and Dividend Compliance Act of 1983.

2159

Form

(Rev. 1-2015)

Catalog No. 21475H

Form 2159 - Payroll Deduction Agreement Page 6

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