Fillable EFTPS Individual Enrollment Form 2011 Form 9783

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EFTPS Individual Enrollment Form 2011 Form 9783

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The EFTPS Individual Enrollment Form 2011 Form 9783 form is 2 pages long and contains:

  • 2 signatures
  • 2 check-boxes
  • 25 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 21820C www.irs.gov
Form
9783 (Rev. 12-2011)
Electronic Federal Tax Payment System
Individual Enrollment
Department of the Treasury - Internal Revenue Service
OMB Number
1545-1467
Visit EFTPS.gov to enroll online.
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, CO 80217-3788
You will receive the information you need to use EFTPS within seven business days after we receive your enrollment
form. Enrolling online via EFTPS.gov saves on mail time; consider enrolling that way.
1a. Primary Social Security Number (SSN). Enter the primary Social Security Number associated with filing. If this enrollment is for
joint filers, enter the SSN of the primary taxpayer. The primary taxpayer is the taxpayer listed first on your tax return. Note: If you
are a Sole Proprietor, without employees, use Form 9783, EFTPS Individual Enrollment and enroll in EFTPS as an Individual,
using the primary Social Security Number associated with filing your Taxpayer Identification Number.
1b. Joint filer’s taxpayer identification number (SSN). If this is a joint filing, provide the joint filer’s Social Security Number.
2. Taxpayer(s) name(s). Print your name exactly as it appears on the tax return. The only valid characters are A-Z, 0-9, -, &, and
blank. For joint filers, enter primary taxpayer name first: JOHN AND MARY SMITH or JOHN SMITH AND MARY JONES.
3. Primary taxpayer address. This address should be the address as it appears on your tax return.
5. Primary contact name. Print the name of the person, company, or third party to contact if questions arise. All EFTPS mailings will
be sent to the primary contact.
6-7. Primary contact mailing address and phone number (if different from item 3 above). If an address is provided here, it will be
used to mail confirmation materials.
Use black or blue ink only.
Print legibly.
Use only CAPITAL letters.
Example
CEDAR RAPIDS IA 52471
City State ZIP Code
Taxpayer Information
1a. Primary Social Security Number (SSN) 1b. Joint filer’s taxpayer identification number (SSN)
2. Taxpayer(s) name(s)
3. Primary taxpayer address
City State ZIP code
International (Provide Province, Country, and Postal code)
4. Primary taxpayer phone number (provide only one)
US number
International number
Contact Information
5. Primary contact name
6. Primary contact mailing address (if different from item 3 above)
City State ZIP code
International (Provide Province, Country, and Postal code)
7. Primary contact phone number (provide only one)
US number International number
Catalog Number 21820C www.irs.gov
Form
9783 (Rev. 12-2011)
Electronic Federal Tax Payment System - Individual Enrollment
Note: If you wish to use multiple accounts in one financial institution or accounts in multiple financial institutions, you will need to
complete a separate form for each enrollment.
9. Routing number (RTN). This is the nine-digit number associated with your financial institution. You may contact your financial
institution to verify this number.
10. Account number. Enter the number of the account you will use to pay your taxes.
12. Authorization. This section authorizes a Financial Agent of the U.S. Department of the Treasury to initiate the payments you
authorize.
13. Taxpayer(s) signature. The taxpayer (and joint filer, if applicable) must sign this section to authorize participation in EFTPS. If
there is no signature, the form will be returned. This section also provides authorization to share the information provided with your
financial institution(s) required for EFTPS processing. If signed on behalf of the taxpayer, the signer certifies authority to execute
this authorization.
Social Security Number
8. Primary Social Security Number (SSN) (Reenter - should match primary SSN on first page)
Financial Institution Information
9. Routing Transit Number (RTN) 10. Account number
11. Type of account
Checking Savings
12. Read the following Authorization Agreements
Authorization
Disclosure Authorization Agreement
I hereby authorize the contact person listed in item 5 on this form and financial institutions involved in the processing of my Electronic Federal Tax Payment System
(EFTPS) payments to receive confidential information necessary to effect enrollment in EFTPS, electronic payment of taxes, answer inquiries and resolve issues related
to enrollment and payments. This information includes, but is not limited to, passwords, payment instructions, taxpayer name and identifying number, and payment
transaction details. This authorization is to remain in full force and effect until the designated Financial Agents of the U.S. Treasury have received written notification from
me of termination in such time and in such manner to afford a reasonable opportunity to act on it.
Debit Authorization Agreement
By completing the financial institution information in items 9-11 on this form, I authorize designated Financial Agents of the U.S. Treasury to initiate EFTPS debit entries
to the financial institution account indicated above, for payment of federal taxes owed to the IRS upon request by Taxpayer or his/her representative, using the Electronic
Federal Tax Payment System (EFTPS). I further authorize the financial institution named above to debit such entries to the financial institution account indicated above.
All debits initiated by the U.S. Treasury designated Financial Agents pursuant to this authorization shall be made under U.S. Treasury regulations. This authorization is to
remain in full force and effect until the designated Financial Agents of the U.S. Treasury have received written notification of termination in such time and in such manner
as to afford a reasonable opportunity to act on it.
Authority to Execute an Authorization
If signed by a corporate officer, partner, or fiduciary on behalf of the taxpayer, I certify that I have the authority to have payments made from the taxpayer’s account. If
signed by a representative of the taxpayer, I certify that I have the authority to execute this authorization on behalf of the taxpayer (i.e., authority provided by Form 2848,
Power of Attorney and Declaration of Representative, or Form 8655, Reporting Agent Authorization for Magnetic Tape/Electronic Filers).
13. Taxpayer(s) signature
Taxpayer name (print)
Taxpayer signature Date signed
Joint filer’s name (print)
Joint filer’s signature Date signed
Remember to sign and mail your business enrollment form to the address on reverse side
For questions regarding
EFTPS or this form, call:
EFTPS Customer Service 1-800-316-6541 (24 hours a day, 7 days a week)
En Español 1-800-244-4829 (24 hours a day, 7 days a week)
For TDD (hearing impaired) support 1-800-733-4829 (8 a.m. to 8 p.m. EST)
Privacy Act and Paperwork Reduction Notice
We ask for the information on this form to carry out the Internal Revenue laws of the United States. We need this information to ensure that you are complying with the revenue laws and to allow us to
figure and collect the right amount of tax. Our authority to ask for this information is 5 U.S.C. 301 and Internal Revenue Code sections 6001, 6011, 6012, and their applicable regulations. Section 6109
requires filers to provide their SSN or other identifying numbers. The information will be used to enroll you in the Electronic Federal Tax Payment System (EFTPS) and to ensure that payment(s) are
properly credited to the appropriate account(s).
Generally, tax returns and return information are confidential, as stated in section 6103 of the Internal Revenue Code. However, section 6103 allows or requires the Internal Revenue Service to disclose
such information to the Department of Justice for civil and criminal litigation, and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws.
We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to
combat terrorism. If you are required by regulation to use electronic funds transfer to make your deposits, your response is mandatory; failure to provide all of the requested information or providing false
or fraudulent information may subject you to penalties. If you are not required by regulation to use electronic funds transfer, your response is voluntary; failure to provide all of the requested information
may prevent processing of this form, and providing false or fraudulent information may subject you to penalties. If you are not required to use electronic funds transfer to pay taxes owed, you need to pay
the taxes due by another method.
You are not required to provide information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or
its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. The time needed to provide this information will vary depending on
individual circumstances. The estimated average time is ten minutes. If you have comments concerning the accuracy of this time estimate or suggestions for reducing this burden, we would be happy to
hear from you. You can write to the IRS Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, IR 6526, Washington, DC 20224. Please do not send the enrollment
form to this address.
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EFTPS Individual Enrollment Form 2011 Form 9783

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Completed 18 May 2019

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