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Department of the Treasury — Internal Revenue Service
Form 2159
(May 2020) Payroll Deduction Agreement
(See Instructions on the back of this page.)
TO: (Employer name and address) Regarding: (Taxpayer name and address)
Contact person’s name Telephone (Include area code) Social security or employer identification number
(Taxpayer) (Spouse, last four digits)
EMPLOYER —S ee the instructions on the back of Part 2. The taxpayer identified above Debit Payments Self-Identifier
on the right named you as an employer. Please read and sign the following statement to
agree to withhold amount(s) from the taxpayer’s (employee’s) wages or salary to apply to If you are unable to make electronic payments through a debit instrument
taxes owed. (debit payments) by entering into a direct debit installment agreement, please
check the box below:
I agree to participate in this payroll deduction agreement and will withhold the amount
shown below from each wage or salary payment due this employee. I will send the money I am unable to make debit payments
to the Internal Revenue Service every: (Check one box.) Note: Not checking this box indicates that you are able but choosing not to
WEEK TWO WEEKS MONTH OTHER (Specify) make debit payments. See Instructions to Taxpayer below for more details.
For assistance, call: 1-800-829-0115 (Business) or
Date by which payments will be sent beginning on . 1-800-829-8374 (Individual – Self-Employed/Business Owners), or
1-800-829-0922 (Individuals – Wage Earners)
Signed: Or write: Campus
Title: Date: (City, State, and ZIP Code)
Kinds of taxes (Form numbers) Tax periods Amount owed as of
$ , plus all penalties and interest provided by law.
I am paid every (Check one): WEEK TWO WEEKS MONTH OTHER (Specify)
I agree to have $ deducted from my wage or salary payments beginning and paid by the employer to the IRS until the total
liability is paid in full. I also agree and authorize this deduction to be increased or decreased as follows:
Date of increase (or decrease) Amount of increase (or decrease) New installment payment amount
Terms of this agreement—By completing and submitting this agreement, you (the taxpayer) agree to the following terms:
• You will make each payment so that we (IRS) receive it by the due date stated on the • We will apply all payments on this agreement in the best interests of the United States.
front of this form. If you cannot make a scheduled payment or accrue an additional Generally, we will apply the payment to the oldest collection statute, which is normally
liability, contact us immediately. the oldest tax year or tax period.
• This agreement is based on your current financial condition. We may modify or terminate • We can terminate your installment agreement if: You do not make installment
the agreement if our information shows that your ability to pay has significantly changed. payments as agreed, you do not pay any other federal tax debt when due, or you do not
You must provide updated financial information when requested. provide financial information when requested.
• While this agreement is in effect, you must file all federal tax returns and pay any • If we terminate your agreement, we may collect the entire amount you owe by levy on
(federal) taxes you owe on time. your income, bank accounts or other assets, or by seizing your property. You will receive
a notice from us prior to termination of your agreement. EXCEPTION: We cannot collect
• We will apply your federal tax refunds or overpayments (if any) to the amount you owe the individual shared responsibility payment under the Affordable Care Act by levy on
until it is fully paid, including any shared responsibility payment under the Affordable your income or seizure.
Care Act.
• We may terminate this agreement at any time if we find that collection of the tax is in
• You must pay a $225 user fee, which we have authority to deduct from your first payment jeopardy.
(s). You may be eligible for a reduced user fee of $43 that may be waived or reimbursed • This agreement may require managerial approval. We'll notify you when we approve or
if certain conditions are met. See Form 13844 for qualifications and instructions. don’t approve the agreement.
• If you default on your installment agreement and we terminate the agreement, you must • We may file a Notice of Federal Tax lien if one has not been filed previously which may
pay a $89 reinstatement fee if we reinstate the agreement. You may be eligible for a negatively impact your credit rating, but we will not file a Notice of Federal Tax Lien on an
reduced user fee of $43 that may be waived or reimbursed if certain conditions are met. individual shared responsibility payment under the Affordable Care Act.
See Form 13844 for qualifications and instructions. We have the authority to deduct this • By signing and submitting this form, you authorize the IRS to contact third parties and to
fee from your first payment(s) after the agreement is reinstated. If reinstated, you agree disclose your tax information to third parties in order to process and administer this
to the terms of this agreement as stated herein. agreement over its duration.
Additional terms (To be completed by IRS)
Your signature Title (If Corporate Officer or Partner) Date
Spouse’s signature (If a joint liability) Date
AGREEMENT LOCATOR NUMBER: Originator’s ID #: Originator Code:
Check the appropriate boxes: Name: Title:
RSI “1” no further review AI “0” Not a PPIA
A NOTICE OF FEDERAL TAX LIEN (Check one box.)
RSI “5” PPIA IMF 2-year review AI “1” Field Asset PPIA
RSI “6” PPIA BMF 2-year review AI “2” All other PPIAs HAS ALREADY BEEN FILED
Agreement Review Cycle: WILL BE FILED IMMEDIATELY
FOR IRS WILL BE FILED WHEN TAX IS ASSESSED
USE ONLY: Earliest CSED:
Check box if pre-assessed modules included MAY BE FILED IF THIS AGREEMENT DEFAULTS
Agreement examined or approved by (Signature, title, function) Date
Part 1 — Acknowledgement Copy (Return to IRS) Catalog Number 21475H www.irs.gov Form 2159 (Rev. 5-2020)
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