Fillable Form 2159 2018 Payroll Deduction Agreement

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Form 2159 2018 Payroll Deduction Agreement

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Form 2159
(July 2018)
Payroll Deduction Agreement
(See Instructions on the back of this page.)
Department of the Treasury — Internal Revenue Service
Catalog No. 21475H www.irs.gov
Form
2159 (Rev. 7-2018)
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 — See the instructions on the back of Part 2. The taxpayer identified above
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
taxes owed.
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
to the Internal Revenue Service every: (Check one box.)
WEEK TWO WEEKS MONTH OTHER (Specify.)
Signed:
Title: Date:
Debit Payments Self-Identifier
If you are unable to make electronic payments through a debit instrument
(debit payments) by entering into a direct debit installment agreement please
check the box below:
I am unable to make debit payments
Note: Not checking this box indicates that you are able but choosing not to
make debit payments. See Instructions to Taxpayer below for more details.
For assistance, call: 1-800-829-0115 (Business) or
1-800-829-8374 (Individual – Self-Employed/Business Owners), or
1-800-829-0922 (Individuals – Wage Earners)
Or write:
(City, State, and ZIP Code)
Campus
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 until the total liability is paid in full. l 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 monthly due
date stated on the front of this form. If you cannot make a scheduled
payment or accrue an additional liability, contact us immediately.
• This agreement is based on your current financial condition. We may modify
or terminate the agreement if our information shows that your ability to pay
has significantly changed. You must provide updated financial information
when requested.
• While this agreement is in effect, you must file all federal tax returns and pay
any (federal) taxes you owe on time.
• We will apply your federal tax refunds or overpayments (if any) to the amount
you owe until it is fully paid, including any shared responsibility payment
under the Affordable Care Act.
• You must pay a $225 user fee, which we have authority to deduct from your
first payment(s). You may be eligible for a reduced user fee of $43 that may
be waived or reimbursed if certain conditions are met. See Form 13844 for
qualifications and instructions.
• If you default on your installment agreement, you must pay a $89
reinstatement fee if we reinstate the agreement. We have the authority to
deduct this fee from your first payment(s) after the agreement is reinstated.
• We will apply all payments on this agreement in the best interests of the
United States. Generally we will apply the payment to the oldest collection
statute, which is normally the oldest tax year or tax period.
• We can terminate your installment agreement if: You do not make monthly
installment payments as agreed, you do not pay any other federal tax debt
when due, or you do not provide financial information when requested.
• If we terminate your agreement, we may collect the entire amount you owe by
levy on 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 the individual shared
responsibility payment under the Affordable Care Act by levy on your income
or seizure.
• We may terminate this agreement at any time if we find that collection of the
tax is in jeopardy.
• This agreement may require managerial approval. We'll notify you when we
approve or don’t approve the agreement.
• We may file a Notice of Federal Tax lien if one has not been filed previously
which may negatively impact your credit rating, but we will not file a Notice of
Federal Tax Lien on an individual shared responsibility payment under the
Affordable Care Act.
Additional Terms (To be completed by IRS)
Note: Internal Revenue Service employees
may contact third parties in order to process
and maintain this agreement.
Your signature Title (If Corporate Officer or Partner) Date
Spouse’s signature (If a joint liability) Date
FOR IRS
USE ONLY:
AGREEMENT LOCATOR NUMBER:
Check the appropriate boxes:
RSI “1” no further review
RSI “5” PPIA IMF 2 year review
RSI “6” PPIA BMF 2 year review
AI “0” Not a PPIA
AI “1” Field Asset PPIA
AI “2” All other PPIAs
Agreement Review Cycle:
Earliest CSED:
Check box if pre-assessed modules included
Originator’s ID #: Originator Code:
Name: Title:
A NOTICE OF FEDERAL TAX LIEN
(Check one box.)
HAS ALREADY BEEN FILED
WILL BE FILED IMMEDIATELY
WILL BE FILED WHEN TAX IS ASSESSED
MAY BE FILED IF THIS AGREEMENT DEFAULTS
Agreement examined or approved by (Signature, title, function) Date
Part 1 — Acknowledgement Copy (Return to IRS)
Reset Form Fields
Form 2159
(July 2018)
Payroll Deduction Agreement
(See Instructions on the back of this page.)
Department of the Treasury — Internal Revenue Service
Catalog No. 21475H www.irs.gov
Form
2159 (Rev. 7-2018)
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 — See the instructions on the back of Part 2. The taxpayer identified above
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
taxes owed.
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
to the Internal Revenue Service every: (Check one box.)
WEEK TWO WEEKS MONTH OTHER (Specify.)
Signed:
Title: Date:
Debit Payments Self-Identifier
If you are unable to make electronic payments through a debit instrument
(debit payments) by entering into a direct debit installment agreement please
check the box below:
I am unable to make debit payments
Note: Not checking this box indicates that you are able but choosing not to
make debit payments. See Instructions to Taxpayer below for more details.
For assistance, call: 1-800-829-0115 (Business) or
1-800-829-8374 (Individual – Self-Employed/Business Owners), or
1-800-829-0922 (Individuals – Wage Earners)
Or write:
(City, State, and ZIP Code)
Campus
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 until the total liability is paid in full. l 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 monthly due
date stated on the front of this form. If you cannot make a scheduled
payment or accrue an additional liability, contact us immediately.
• This agreement is based on your current financial condition. We may modify
or terminate the agreement if our information shows that your ability to pay
has significantly changed. You must provide updated financial information
when requested.
• While this agreement is in effect, you must file all federal tax returns and pay
any (federal) taxes you owe on time.
• We will apply your federal tax refunds or overpayments (if any) to the amount
you owe until it is fully paid, including any shared responsibility payment
under the Affordable Care Act.
• You must pay a $225 user fee, which we have authority to deduct from your
first payment(s). You may be eligible for a reduced user fee of $43 that may
be waived or reimbursed if certain conditions are met. See Form 13844 for
qualifications and instructions.
• If you default on your installment agreement, you must pay a $89
reinstatement fee if we reinstate the agreement. We have the authority to
deduct this fee from your first payment(s) after the agreement is reinstated.
• We will apply all payments on this agreement in the best interests of the
United States. Generally we will apply the payment to the oldest collection
statute, which is normally the oldest tax year or tax period.
• We can terminate your installment agreement if: You do not make monthly
installment payments as agreed, you do not pay any other federal tax debt
when due, or you do not provide financial information when requested.
• If we terminate your agreement, we may collect the entire amount you owe by
levy on 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 the individual shared
responsibility payment under the Affordable Care Act by levy on your income
or seizure.
• We may terminate this agreement at any time if we find that collection of the
tax is in jeopardy.
• This agreement may require managerial approval. We'll notify you when we
approve or don’t approve the agreement.
• We may file a Notice of Federal Tax lien if one has not been filed previously
which may negatively impact your credit rating, but we will not file a Notice of
Federal Tax Lien on an individual shared responsibility payment under the
Affordable Care Act.
Additional Terms (To be completed by IRS)
Note: Internal Revenue Service employees
may contact third parties in order to process
and maintain this agreement.
Your signature Title (If Corporate Officer or Partner) Date
Spouse’s signature (If a joint liability) Date
FOR IRS
USE ONLY:
AGREEMENT LOCATOR NUMBER:
Check the appropriate boxes:
RSI “1” no further review
RSI “5” PPIA IMF 2 year review
RSI “6” PPIA BMF 2 year review
AI “0” Not a PPIA
AI “1” Field Asset PPIA
AI “2” All other PPIAs
Agreement Review Cycle:
Earliest CSED:
Check box if pre-assessed modules included
Originator’s ID #: Originator Code:
Name: Title:
A NOTICE OF FEDERAL TAX LIEN
(Check one box.)
HAS ALREADY BEEN FILED
WILL BE FILED IMMEDIATELY
WILL BE FILED WHEN TAX IS ASSESSED
MAY BE FILED IF THIS AGREEMENT DEFAULTS
Agreement examined or approved by (Signature, title, function) Date
Part 2 — Employer’s Copy
Catalog No. 21475H www.irs.gov
Form 2159 (Rev. 7-2018)
INSTRUCTIONS TO EMPLOYER
This payroll deduction agreement is subject to your approval. If you agree to participate, please complete the spaces provided
under the employer section on the front of this form.
WHAT YOU SHOULD DO
• Enter the name and telephone number of a contact person. (This will allow us to contact you if your employee’s liability is
satisfied ahead of time.)
• Indicate when you will forward payments to IRS.
• Sign and date the form.
• After you and your employee have completed and signed all parts of the form, please return the parts of the form which
were requested on the letter the employee received with the form. Use the IRS address on the letter the employee
received with the form or the address shown on the front of the form.
HOW TO MAKE PAYMENTS
Please deduct the amount your employee agreed with the IRS to have deducted from each wage or salary payment due
the employee.
Make your check payable to the “United States Treasury.” To insure proper credit, please write your employee’s name
and social security number on each payment.
Send the money to the IRS mailing address printed on the letter that came with the agreement. Your employee should
give you a copy of this letter. If there is no letter, use the IRS address shown on the front of the form.
Note: The amount of the liability shown on the form may not include all penalties and interest provided by law. Please continue to
make payments unless IRS notifies you that the liability has been satisfied. When the amount owed, as shown on the form, is paid
in full and IRS hasn’t notified you that the liability has been satisfied, please call the appropriate telephone number below to
request the final balance due.
If you need assistance, please call the telephone number on the letter that came with the agreement or write to the address shown
on the letter. If there’s no letter, please call the appropriate telephone number below or write IRS at the address shown on the
front of the form.
For assistance, call: 1-800-829-0115 (Business), or
1-800-829-8374 (Individual – Self-Employed/Business Owners), or
1-800-829-0922 (Individuals – Wage Earners)
THANK YOU FOR YOUR COOPERATION
Form 2159
(July 2018)
Payroll Deduction Agreement
(See Instructions on the back of this page.)
Department of the Treasury — Internal Revenue Service
Catalog No. 21475H www.irs.gov
Form
2159 (Rev. 7-2018)
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 — See the instructions on the back of Part 2. The taxpayer identified above
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
taxes owed.
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
to the Internal Revenue Service every: (Check one box.)
WEEK TWO WEEKS MONTH OTHER (Specify.)
Signed:
Title: Date:
Debit Payments Self-Identifier
If you are unable to make electronic payments through a debit instrument
(debit payments) by entering into a direct debit installment agreement please
check the box below:
I am unable to make debit payments
Note: Not checking this box indicates that you are able but choosing not to
make debit payments. See Instructions to Taxpayer below for more details.
For assistance, call: 1-800-829-0115 (Business) or
1-800-829-8374 (Individual – Self-Employed/Business Owners), or
1-800-829-0922 (Individuals – Wage Earners)
Or write:
(City, State, and ZIP Code)
Campus
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 until the total liability is paid in full. l 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 monthly due
date stated on the front of this form. If you cannot make a scheduled
payment or accrue an additional liability, contact us immediately.
• This agreement is based on your current financial condition. We may modify
or terminate the agreement if our information shows that your ability to pay
has significantly changed. You must provide updated financial information
when requested.
• While this agreement is in effect, you must file all federal tax returns and pay
any (federal) taxes you owe on time.
• We will apply your federal tax refunds or overpayments (if any) to the amount
you owe until it is fully paid, including any shared responsibility payment
under the Affordable Care Act.
• You must pay a $225 user fee, which we have authority to deduct from your
first payment(s). You may be eligible for a reduced user fee of $43 that may
be waived or reimbursed if certain conditions are met. See Form 13844 for
qualifications and instructions.
• If you default on your installment agreement, you must pay a $89
reinstatement fee if we reinstate the agreement. We have the authority to
deduct this fee from your first payment(s) after the agreement is reinstated.
• We will apply all payments on this agreement in the best interests of the
United States. Generally we will apply the payment to the oldest collection
statute, which is normally the oldest tax year or tax period.
• We can terminate your installment agreement if: You do not make monthly
installment payments as agreed, you do not pay any other federal tax debt
when due, or you do not provide financial information when requested.
• If we terminate your agreement, we may collect the entire amount you owe by
levy on 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 the individual shared
responsibility payment under the Affordable Care Act by levy on your income
or seizure.
• We may terminate this agreement at any time if we find that collection of the
tax is in jeopardy.
• This agreement may require managerial approval. We'll notify you when we
approve or don’t approve the agreement.
• We may file a Notice of Federal Tax lien if one has not been filed previously
which may negatively impact your credit rating, but we will not file a Notice of
Federal Tax Lien on an individual shared responsibility payment under the
Affordable Care Act.
Additional Terms (To be completed by IRS)
Note: Internal Revenue Service employees
may contact third parties in order to process
and maintain this agreement.
Your signature Title (If Corporate Officer or Partner) Date
Spouse’s signature (If a joint liability) Date
FOR IRS
USE ONLY:
AGREEMENT LOCATOR NUMBER:
Check the appropriate boxes:
RSI “1” no further review
RSI “5” PPIA IMF 2 year review
RSI “6” PPIA BMF 2 year review
AI “0” Not a PPIA
AI “1” Field Asset PPIA
AI “2” All other PPIAs
Agreement Review Cycle:
Earliest CSED:
Check box if pre-assessed modules included
Originator’s ID #: Originator Code:
Name: Title:
A NOTICE OF FEDERAL TAX LIEN
(Check one box.)
HAS ALREADY BEEN FILED
WILL BE FILED IMMEDIATELY
WILL BE FILED WHEN TAX IS ASSESSED
MAY BE FILED IF THIS AGREEMENT DEFAULTS
Agreement examined or approved by (Signature, title, function) Date
Part 3 — Taxpayer’s Copy
Catalog No. 21475H www.irs.gov
Form 2159 (Rev. 7-2018)
INSTRUCTIONS TO TAXPAYER
If not already completed by an IRS employee, please fill in the information in the spaces provided on the front of this form for the
following items:
• Your employer’s name and address
• Your name(s) (plus spouse’s name if the amount owed is for a joint return) and current address.
• Your social security number or employer identification number. (Use the number that appears on the notice(s) you
received.) Also, enter the last four digits of your spouse’s social security number if this is a joint liability.
• If you are a low-income taxpayer you would qualify for the waiver of your installment agreement fees if you agreed to make
electronic payments through a debit instrument (debit payments) by entering into a direct debit installment agreement.
This payroll deduction agreement is not a direct debit installment agreement and you are not making debit payments
under this agreement. However, if you indicated in the Debit Payments Self-Identifier section of this agreement that you
are unable to make debit payments by entering into a direct debit installment agreement, then your installment agreement
fees will be reimbursed upon completion of your agreement. Low-income taxpayers, for installment agreement purposes,
are individuals with adjusted gross incomes, as determined for the most recent year for which such information is
available, at or below 250% of the criteria established by the poverty guidelines updated annually by the U.S. Department
of Health and Human Services.
• The kind of taxes you owe (form numbers) and the tax periods
• The amount you owe as of the date you spoke to IRS
• When you are paid
• The amount you agreed to have deducted from your pay when you spoke to IRS
• The date the deduction is to begin
• The amount of any increase or decrease in the deduction amount, if you agreed to this with IRS; otherwise, leave BLANK
After you complete, sign (along with your spouse if this is a joint liability), and date this agreement form, give it to your participating
employer. If you received the form by mail, please give the employer a copy of the letter that came with it.
Your employer should mark the payment frequency on the form and sign it. Then, your employer should return the parts of the
form which were requested on your letter or return Part 1 of the form to the address shown in the “For assistance” box on the front
of the form.
If you need assistance, please call the appropriate telephone number below or write IRS at the address shown on the form.
However, if you received this agreement by mail, please call the telephone number on the letter that came with it or write IRS at
the address shown on the letter.
For assistance, call: 1-800-829-0115 (Business), or
1-800-829-8374 (Individual – Self-Employed/Business Owners), or
1-800-829-0922 (Individuals – Wage Earners)
Note: This agreement will not affect your liability (if any) for backup withholding under Public Law 98-67, the Interest and
Dividend Compliance Act of 1983.
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Form 2159 2018 Payroll Deduction Agreement

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Completed 30 March 2020

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