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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)
