PDF document

- 1 -

Tax Form 9783 with Instructions (OMB 1545-1467) Department of the Treasury

Individual Enrollment Form for EFTPS – This form contains instructions to complete the Electronic Federal Tax Payment System
(EFTPS) Enrollment Form for Individual Taxpayers. It is to be used either for initial enrollment in the system or to add financial institution information. If you wish
to use multiple accounts in one financial institution, or accounts in multiple financial institutions, you will need to provide multiple copies of the enrollment form.
For questions regarding EFTPS or this Enrollment Form please call: EFTPS Customer Service 1-800-316-6541
For TDD (hearing impaired) support 1-800-733-4829
Visit our web site at www.EFTPS.gov to enroll online. 24 hours a day, 7 days a week en español 1-800-244-4829

EFTPS Enrollment Processing Center
➪ When your form is completed, please mail to:
P.O. Box 173788, Denver, Colorado 80217-3788
You should receive your Confirmation/Update Form and instructions on using EFTPS approximately two to four weeks after we receive your Enrollment Form.
Marking Instructions: • Use black or blue ink only. MARKING EXAMPLE:
INSTRUCTIONS • Please print legibly. Use one character per block.
1. Primary Taxpayer Identification Use only capital letters. Keep all printing within the boxes. IA 52471
Number (SSN). Enter your nine-digit
Social Security Number. If this enrollment • Do not make any stray marks on this form. State Zip Code
is for joint filers, enter the SSN of the Taxpayer Information
primary taxpayer. The primary taxpayer
is the taxpayer listed first on your tax 1. Primary Taxpayer Identification Number (SSN) – (Please enter SSN on reverse side also):
return. Enter the SSN on the back of the
form in the upper right corner as well.
Sole Proprietor Businesses, without 2. Taxpayer(s) Name:
employees; enroll as an Individual and
use your Social Security Number as your
Taxpayer Identification Number.
2. Taxpayer Name(s). Print your name 3. Joint Filer’s Taxpayer Identification Number (SSN):
exactly as it appears on the tax return.
The only valid characters are A-Z, 0-9, -,
&, and blank. For joint filers, enter 4. Primary Taxpayer Address:
primary taxpayer name first: JOHN AND
MARY SMITH, or JOHN SMITH AND
MARY JONES.
3. Joint Filer Taxpayer Identification City: State: Zip Code:
Number (SSN). If this is a joint filing,
please provide the joint filer’s Social
Security Number. International: Province, Country, and Postal Code:
4. Primary Taxpayer Address. This
address should be the address as it
appears on your tax return.
5. Primary Taxpayer Phone Number:SAMPLE
✍Note: If the address is incorrect, US Area Code International Country Code City Code
it can only be changed by submitting
an IRS Change of Address (Form 011-
8822) to the Internal Revenue
Service. The address on your EFTPS
enrollment will automatically be
updated when Form 8822 is submitted. Contact Information
See the back of Form 8822 to 6. Primary Contact Name (if different from #2 above):
determine where the form should be
mailed.
5. Primary Taxpayer Phone Number. 7. Primary Contact Mailing Street Address (if different from #4 above):
Provide your area code and phone
number.
6. Primary Contact Name. Print the
name of a person, company, or third City: State: Zip Code:
party who can be contacted in the event
questions arise regarding this enrollment
or tax payments. All EFTPS mailings will International: Province, Country, and Postal Code:
be sent to your primary contact.
7-8. Primary Contact Mailing Address
and Phone Number (if different from #4 8. Primary Contact Phone Number (if different from #5 above):
above). You need not complete the US Area Code International Country Code City Code
address and phone section if your
contact’s address and phone is the same 011-
as the primary taxpayer. If an address is
provided here, it will be used to mail 9. Primary Contact E-mail Address (use as many spaces as needed up to 60):
confirmation materials and instruction
booklets.
9. Primary Contact E-mail Address.
(optional)

(over)

- 2 -

For side 2 please fill in
(continued) Social Security Number (SSN)
SSN:

Payment Information
10. Payment Method. Check EFTPS as
your payment method if you will instruct 10. Payment Method
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
interchangeable: Internet and phone. (You can interchange input payment methods: Internet and/or phone).

Tax Form Payment Amount Limit
11. Tax Form Payment Amount Limit
This section is optional. You may set an 11. $
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
you exceed the limit. You may override Financial Institution Information
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
financial institution to verify this number. Savings
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
Code. Use the two-character letter Authorization
abbreviation for the state your financial
institution is located in and indicate Zip 16. Please read the following Authorization Agreement:
Code.
16. Authorization. This section authorizes 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 involvedSAMPLE
a Financial Agent of the U.S. Treasury to in the processing of my Electronic Federal Tax Payment System (EFTPS) payments to receive confidential information necessary to effect enrollment in EFTPS,
initiate tax payments from the account(s) electronic payment of taxes, and answer inquiries and resolve issues related to enrollment and payments. This information includes, but is not limited to,
you designate for EFTPS. passwords, payment instructions, taxpayer name and identifying number, and payment transaction details. If signed by someone other than the taxpayer, I
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
will be returned. 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
This section also provides authorization the Electronic Federal Tax Payment System (EFTPS). I further authorize the financial institution named above to debit such entries to the financial institution
to share the information provided with 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
your financial institution, required for the 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
processing of the Electronic Federal Tax from me of termination in such time and in such manner as to afford a reasonable opportunity to act on it.
Payment System.
If signed on behalf of the individual 17. Taxpayer Signature
taxpayer, the signer certifies that they
have the authority to execute this Date
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.
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:
1996–405-503/41610 Form 9783 (7/05)
Cat. No.: 21820C

PDF file checksum: 4233567199

(Plugin #1/7.24/11.3)