PDF document

- 1 -

Tax Form 9779 with Instructions (OMB 1545-1467) Department of the Treasury

Business Enrollment Form for EFTPS – This form contains instructions to complete the Electronic Federal Tax Payment System
(EFTPS) Enrollment Form for Business 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 1-800-555-4477
Visit our web site at www.EFTPS.gov to enroll online. For TDD (hearing impaired) support 1-800-733-4829
en español 1-800-244-4829
24 hours a day, 7 days a week

➪ When your form is completed, please mail to: EFTPS Enrollment Processing Center
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.

INSTRUCTIONS Marking Instructions: • Use black or blue ink only. MARKING EXAMPLE:
1. Employer Identification Number • Please print legibly. Use one character per block. Use
(EIN). Enter your nine-digit Employer only capital letters. Keep all printing within the boxes. IA 52471
Identification Number. Enter the EIN on
the back of the form in the upper right • Do not make any stray marks on this form. State Zip Code
corner as well. Taxpayer Information
Note to Sole Proprietors: if you are a
Sole Proprietor business, without 1. Employer Identification Number (EIN) – (Please enter EIN on reverse side also.)
employees, you need to enroll as an
Individual (Tax Form 9783) and use your
Social Security Number as your Taxpayer
Identification Number. 2. Business Taxpayer Name:
2. Business Taxpayer Name. Print your
business name exactly as it appears on
the tax return. Sole Proprietors should
use the individual owners name rather 3. Business Street Address:
than the DBA name. The only valid
characters are A-Z, 0-9, -, &, and blank.
3. Business Address. This address City: State: ZIP Code:
should be the address as it appears on
the business tax return.
✍ Note: If the address has been International: Province, Country, and Postal Code:
pre-printed and is incorrect, it can
only be changed by submitting an
IRS Change of Address (Form 8822)
to the Internal Revenue Service. The SAMPLE
address on your EFTPS enrollment
will automatically be updated when Contact Information
Form 8822 is submitted. See the 4. Primary Contact Name:
back of Form 8822 to determine
where the form should be mailed.
5. Primary Contact Mailing Street Address (if different from #3 above):
4. Primary Contact Name. Print the
name of a person, company, or third
party who can be contacted in the event City: State: Zip Code:
questions arise regarding this enrollment
or tax payments. All EFTPS mailings will
be sent to your primary contact.
5-6. Primary Contact Mailing Address International: Province, Country, and Postal Code:
and Phone Number (if different from #3
above). You need not complete the
address area if your contact’s address is 6. Primary Contact Phone Number:
the same as the business address. If an US Area Code International Country Code City Code
address is provided here, it will be used 011-
to mail confirmation materials and
instruction booklets. 7. Primary Contact E-mail Address (use as many spaces as needed up to 60):
7. Primary contact E-mail Address.
(optional)

(over)

- 2 -

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
phone and EFTPS through a Financial EFTPS (through a Financial Institution): check here if you will instruct your financial institution to forward the payment to EFTPS.
Institution. Both EFTPS input methods You must check with your financial institution to determine if they are capable of providing this service.
are interchangeable: Internet and phone. NOTE: If you will only be using EFTPS through your Financial Institution as a payment method, skip to item #23.

✍ 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 9. 10. $$$11.
Amount Limits (For EFTPS using the
Internet or phone only) 720 ,, 940 ,, 941 ,,
This section is optional. You may set 12. $$$13. 14.
amount limits for each tax type to 943 ,, 945 ,, 990C ,,
prevent an overpayment. The system will
compare your payment amount against 15. $$$16. 17.
your stated limit and provide a warning if 990PF ,, 990T ,, 1042 ,,
you exceed the limit. You may override
the warning if you wish. 18. $
1120 ,,
(19 through 24 must be completed if
EFTPS using the Internet or phone will
be used) Financial Institution Information (to be completed if EFTPS using the Internet or phone will be used)
19. RTN. This is the nine-digit number 19. RTN: 20. Account Number: 21. Type:
associated with your financial institution. Checking
You may contact your financial institution
to verify this number. Savings
SAMPLE
20. Account Number. Enter the number 22. State: ZIP Code:
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
savings account. Authorization
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
indicate ZIP Code. in the processing of my Electronic Federal Tax Payment System (EFTPS) payments to receive confidential information necessary to effect enrollment in EFTPS,
electronic payment of taxes, and answer inquiries and resolve issues related to enrollment and payments. This information includes, but is not limited to, passwords,
23. Authorization. This section authorizes payment instructions, taxpayer name and identifying number, and payment transaction details. If signed by a corporate officer, partner, or fiduciary on behalf of
a Financial Agent of the U.S. Treasury to 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
initiate tax payments from the account(s) 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
you designate. opportunity to act on it.
24. Taxpayer Signature. The taxpayer Only EFTPS using the Internet or phone: Please read the following Authorization Agreement:
must sign this section to authorize
participation in EFTPS. If there is no 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
signature, a form 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
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,
or fiduciary on behalf of the taxpayer, Date
the signer certifies that they have the Taxpayer Signature
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:
1998–405-503/41607
Cat. No.: 21816U Form 9779 (2/07)

PDF file checksum: 672614284

(Plugin #1/7.24/11.3)