Catalog Number 69159Q
14781 (9-2016)
Form 14781
(September 2016)
Department of the Treasury - Internal Revenue Service
Electronic Federal Tax Payment System (EFTPS) –
Insolvency Registration
OMB Number
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
This form can be mailed or sent via facsimile (see information at the top of this form.)
click to sign
click to edit
dd mmm yyyy
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome