Department of the Treasury – Internal Revenue Service
Form
13287
(December 2009)
Bank Payment Problem Identification
Section I.
Part 1: Taxpayer Information
(For completion by bank)
Information Supplied by Bank
1. Taxpayer Identification Number (TIN)
(DO NOT enter the EIN of the taxpayer's bank.)
2. Multiple TINs
Yes
(See attached list)
3. Form(s) Payment Intended For (if known) 4. Tax Period(s) Payment Intended For
(if known)
Part 2: Bank Information (For completion by bank)
5. Name of Bank
(Enter complete legal name of responsible bank)
6. Federal Employer Identification Number
(FEIN) of Bank
7. Bank Branch Street Address
8. Branch Number of Bank Where Problem
Occurred
9. City, State, ZIP Code
10. American Banking Association
(ABA) Number
11. Bank Contact Name and Title
(Please print)
12. Telephone Number
13. FAX Number
14. Number of Payments Delayed 15. Payment / Combined Payments Amount
$
17. Date T/P Requested
Payment
(explain in item 26)
18. Date Payment
Transmitted
19. Number of Days
Payment Late
16. Method of Payment
(“x” proper box)
ACH debit ACH credit Coupon
Fed wire
20. Date IRS was
Contacted
21. Mode of Contact
(“x” proper box)
Phone FAX Letter
22. Problem Involved Multiple Payments
Yes
(See attached list.) No
23. Deposit Made More than 48 Hours After
Problem Discovered
No Yes (Explain in Item 25.)
24. IRS Contacted within 48 Hours of Problem
Discovery
No
(Explain in Item 25.)Yes
Signature
Authorization of
Bank Official
25. Explanation
(Items 23 and 24)
26. Brief explanation why payment could not be processed as taxpayer requested
By signing below, I understand that the financial institution listed above will accept responsibility for the payment
(s) delay.
27. Name
(Please print) 28. Title
29. Signature
30. Date
Section II.
INFORMATION SUPPLIED BY INTERNAL REVENUE SERVICE
Part 3: IRS Information (For completion by IRS)
31. History 32. Resolution
33. Name of Taxpayer 34. Taxpayer
Correspondence Date
35. Date Bank's Completed Form
13287 received at IRS
36. Method of Taxpayer Contact
(“x” proper box)
Phone FAX Letter
37. TC 971
Action Code 30 ___
38. Payment Date 39. Intended Payment Date 40. Additional Action(s) for Adjustment(s)
to Account
(TC 181, ADX 48/24/34)
41. IRS Contact Name (Please print) 42. IRS Contact Employee
Number
43. IRS Contact Phone Number
44. IDRS Input Date
(mm/dd/yyyy) 45. Master File Projected 23C
Posting Date
46. Date Information FAXd to Federal
Reserve Board (FRB)
Catalog No. 34294M
www.irs.gov
Form 13287 (Rev. 12-2009)
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Instructions for Completing Form 13287, Bank Problem Identification Worksheet
GENERAL— When a bank delays forwarding a taxpayer's “timely received with proper instructions” Federal Tax Deposit
(FTD) to the U.S. Treasury, the taxpayer may be relieved of the portion of the FTD penalty pertaining to that payment, if the
bank accepts responsibility for the delay. For each delayed FTD payment or issue, FAX a separate Form 13287 and
Instructions to the responsible bank for completion and a bank official's signature. The signed form then becomes the
authorization for the Federal Reserve Board (FRB) to charge the bank for the loss of funds to the U.S. Treasury.
SECTION I. INFORMATION SUPPLIED BY BANK
Part 1: Taxpayer Information
(Items 1 thru 4 for completion by bank)
Item 1: Taxpayer Identification Number (TIN)
Enter the Employer Identification Number (EIN) or Social
Security Number (SSN) of the taxpayer. (DO NOT enter the
EIN of the taxpayer's bank.)
Item 2: Multiple TIN(s)
If multiple TINs (clients) are involved in this issue, please
indicate this and attach a list to this document. The list should
include the clients’ TIN(s), the deposit date(s), the deposit
amount(s), and the form(s) and tax period(s) where the deposit
was intended.
Item 3: Form(s)
Enter the Form number of the account where the deposit was
intended (if known). If the payment was submitted for an
incorrect form number, please notate that form in Item # 26.
Item 4: Tax Period(s)
Enter the Tax Period of the account where the deposit was
intended (if known). If the payment was submitted for an
incorrect tax period, please notate that tax period in Item # 26.
Part 2: Bank Information
(Items 5 thru 30 for completion by bank)
Item 10: American Banking Association (ABA) Number —
Enter the ABA number of the responsible bank for assessment
of the cost of funds (loss of interest).
Item 11: Bank Contact Name and Title —
Enter the name and title of the bank contact person who can
discuss this issue.
Item 14: Number of Payments Delayed —
If only one payment was delayed, enter “1” in this block. If
more than one, enter the total and attach a separate
spreadsheet which shows the breakdown by TIN of the
individual payment amounts (see Item # 2).
Item 15: Payment / Combined Payments Amount —
Enter the single payment amount or, if multiple payments are
involved, enter the total of all delayed payments.
Item 17: Date T/P Requested Payment (mm/dd/yyyy) —
Enter the date the taxpayer requested the payment to post to
their IRS account. (This usually is the due date.)
Item 19: Number of Days Payment Late —
Enter the number of days elapsed between the date the
payment should have been posted to the taxpayer's IRS
account and the date it actually posted (settlement date and
the intended settlement date).
Item 20: Date IRS was contacted (mmddyyyy) —
Enter the date the IRS was first contacted about the issue.
SECTION II. INFORMATION SUPPLIED BY IRS
Part 3: IRS Information
(Items 31 thru 46 for completion by IRS)
Item 31: History —
Enter a brief history of any actions, contacts, etc.
Item 32: Resolution —
Enter a brief history of actions taken to resolve this issue.
Item 33: Name of Taxpayer —
If the case only involves one TIN, list the name of the
taxpayer(s) or business.
Item 34: Taxpayer correspondence date (mmddyyyy)
Enter the date the taxpayer first contacted IRS about this
issue.
Item 36: Method of Taxpayer Contact (mm/dd/yyyy)
Enter the mode the taxpayer used to contact the IRS about
this issue.
Item 37: TC 971 —
For TC971 input, enter “1 – 9” for action codes 301-309. If
TC971 cannot be input, prepare a Form 8646, Checklist to
Identify Delays in Processing Federal Tax Deposits (FTDs).
Item 38: Payment Date (mm/dd/yyyy )
Enter the date the payment was posted to the taxpayer's
account.
Item 39: Intended Payment Date (mm/dd/yyyy )
Enter the date the payment should have posted to the
taxpayer's account.
Item 40: Additional Action(s) for Adjustment(s) to
Account (TC 181, ADX 48/24/34)
Enter any other actions taken in addition to the TC 971 (or in
place of).
Item 41: IRS contact name —
Enter the name of the person who worked the case.
Catalog No. 34294M
www.irs.gov
Form 13287 (Rev. 12-2009)
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