Payroll Deduction Agreement
(See Instructions on the back of this page.)
Department of the Treasury — Internal Revenue Service
Catalog No. 21475H www.irs.gov
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
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.)
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)
(City, State, and ZIP Code)
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
• 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
• 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
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:
Check box if pre-assessed modules included
Originator’s ID #: Originator Code:
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)
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