Fillable Form 9783 - Eftps Individual Enrollment Form (2005) (Page 2 of 2) in pdf

For side 2 please fill in

(continued)

Social Security Number (SSN)

SSN:

Payment Information

10. Payment Method. Check EFTPS as

10. Payment Method

your payment method if you will instruct

EFTPS to transfer payment from your

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

account. Both EFTPS input methods are

(You can interchange input payment methods: Internet and/or phone).

interchangeable: Internet and phone.

Tax Form Payment Amount Limit

11. Tax Form Payment Amount Limit

11.

This section is optional. You may set an

amount limit for the tax type to prevent

an overpayment. The system will

compare your payment amount against

your stated limit and provide a warning if

Financial Institution Information

you exceed the limit. You may override

the warning if you wish.

12. Routing Number (RTN). This is the

12. RTN:

13. Account Number:

14. Type:

nine-digit number associated with your

Checking

financial institution. You may contact your

Savings

financial institution to verify this number.

13. Account Number. Enter the number

15. State:

Zip Code:

of the account you will use to pay your

taxes.

14. Type. Please mark one box to indicate

whether the account is a checking or

savings account.

15. Financial Institution State and Zip

Authorization

Code. Use the two-character letter

abbreviation for the state your financial

16. Please read the following Authorization Agreement:

institution is located in and indicate Zip

Code.

I (as defined by the taxpayer whose signature is below) hereby authorize the contact person (listed on this form in item #6) and financial institutions involved

16. Authorization. This section authorizes

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

a Financial Agent of the U.S. Treasury to

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

initiate tax payments from the account(s)

passwords, payment instructions, taxpayer name and identifying number, and payment transaction details. If signed by someone other than the taxpayer, I

you designate for EFTPS.

certify that I have the authority (i.e., Form 2848 Power of Attorney and Declaration of Representative or other Power of Attorney) to execute this authorization on

17. Taxpayer Signature. The taxpayer

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

(and joint filer, if applicable) must sign

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

this section to authorize participation in

EFTPS. If there is no signature, the form

By completing the information in boxes 12-15 and signing below, I hereby authorize designated Financial Agents of the U.S. Treasury to initiate EFTPS debit

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

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.

17. Taxpayer Signature

If signed on behalf of the individual

taxpayer, the signer certifies that they

Date

have the authority to execute this

authorization on behalf of the taxpayer.

Taxpayer Signature

Remember to sign and mail your

Print Name

enrollment form to the address on

reverse side.

Date

Joint Filer’s Signature

Print Name

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

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. 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:

2006–321-822/02771

Form 9783 (7/05)

Cat. No.: 21820C