Fillable F14781 Form 14781 (9-2016)

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F14781 Form 14781 (9-2016)

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The F14781 Form 14781 (9-2016) form is 1 page long and contains:

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  • 0 check-boxes
  • 21 other fields

Country of origin: US
File type: PDF

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The Internal Revenue Service (IRS) is a government agency responsible for collecting taxes and administering the federal statutory tax laws of the United States. The IRS provide tax assistance to taxpayers and pursue and resolve fraudulent tax filings.

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Catalog Number 69159Q www.irs.gov
Form
14781 (9-2016)
Form 14781
(September 2016)
Department of the Treasury - Internal Revenue Service
Electronic Federal Tax Payment System (EFTPS) –
Insolvency Registration
OMB Number
1545-1467
For questions or more information please call EFTPS Provider Help Desk at 1-866-553-9413.
When your form is completed, please mail or send by facsimile to: Internal Revenue Service, Attn: Michael Mancini, 2970 Market
Street, MDP 2-J08.112, Philadelphia, PA 19104-5016 or Fax number 1-888-201-0517
Trustee Information
1. Trustee Taxpayer Identification Number (TIN) (enter your Trustee nine-digit Employer Identification Number, without dashes)
2. Trustee name (print/type) (the only valid characters are A-Z, 0-9, -, &, and blank)
3. Trustee address (print/type your mailing address)
City State ZIP code
–
Contact Information
4. Primary contact name (print/type the name of a person who can be contacted in the event
questions arise regarding this form)
Primary contact telephone number
Area code
/ –
Primary contact email address
.
Software Vendor & Bank Information
Software Vendor and Bank Name (print/type name vendor and phone number of your software, and name of your bank)
5. Software vendor name Software vendor telephone number
Area code
/ –
Bank name
Trustee Signature
The registration from must be signed to authorize participation in the EFTPS program.
6. If signed by a Corporate Officer, Partner, or Fiduciary on behalf of the trustee, he/she certifies that the undersigned has the authority
to execute this authorization on behalf of the trustee
Authorized signature Date
Name (print/type) Title
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F14781 Form 14781 (9-2016)

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Completed 6 June 2020

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