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
This form can be mailed or sent via facsimile (see information at the top of this form.)
click to sign
signature
click to edit
dd mmm yyyy
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