Form 9779 EFTPS Business Enrollment Form

Tax Form 9779 with Instructions (OMB 1545-1467)

Department of the Treasury

Business Enrollment Form for EFTPS –

This form contains instructions to complete the Electronic Federal Tax Payment System
(EFTPS) Enrollment Form for Business Taxpayers. It is to be used either for initial enrollment in the system or to add financial institution information. If you wish to
use multiple accounts in one financial institution, or accounts in multiple financial institutions, you will need to provide multiple copies of the enrollment form.

For questions regarding EFTPS or this Enrollment Form please call:

Visit our web site at www.EFTPS.gov to enroll online.
24 hours a day, 7 days a week

➪

When your form is completed, please mail to:

EFTPS Customer Service

1-800-555-4477

For TDD (hearing impaired) support
en español

1-800-733-4829
1-800-244-4829

EFTPS Enrollment Processing Center
P.O. Box 173788
Denver, Colorado 80217-3788

You should receive your Confirmation/Update Form and instructions on using EFTPS approximately two to four weeks after we receive your Enrollment Form.

INSTRUCTIONS
1. Employer Identification Number
(EIN). Enter your nine-digit Employer
Identification Number. Enter the EIN on
the back of the form in the upper right
corner as well.
Note to Sole Proprietors: if you are a
Sole Proprietor business, without
employees, you need to enroll as an
Individual (Tax Form 9783) and use your
Social Security Number as your Taxpayer
Identification Number.
2. Business Taxpayer Name. Print your
business name exactly as it appears on
the tax return. Sole Proprietors should
use the individual owners name rather
than the DBA name. The only valid
characters are A-Z, 0-9, -, &, and blank.
3. Business Address. This address
should be the address as it appears on
the business tax return.

✍

Note: If the address has been
pre-printed and is incorrect, it can
only be changed by submitting an
IRS Change of Address (Form 8822)
to the Internal Revenue Service. The
address on your EFTPS enrollment
will automatically be updated when
Form 8822 is submitted. See the
back of Form 8822 to determine
where the form should be mailed.

MARKING EXAMPLE:

Marking Instructions: • Use black or blue ink only.
• Please print legibly. Use one character per block. Use
only capital letters. Keep all printing within the boxes.
• Do not make any stray marks on this form.

IA

5247 1

State

Zip Code

Taxpayer Information
1. Employer Identification Number (EIN) – (Please enter EIN on reverse side also.)

2. Business Taxpayer Name:

3. Business Street Address:

City:

State:

ZIP Code:

State:

Zip Code:

International: Province, Country, and Postal Code:

Contact Information
4. Primary Contact Name:

5. Primary Contact Mailing Street Address (if different from #3 above):
4. Primary Contact Name. Print the
name of a person, company, or third
party who can be contacted in the event
questions arise regarding this enrollment
or tax payments. All EFTPS mailings will
be sent to your primary contact.
5-6. Primary Contact Mailing Address
and Phone Number (if different from #3
above). You need not complete the
address area if your contact’s address is
the same as the business address. If an
address is provided here, it will be used
to mail confirmation materials and
instruction booklets.

City:

International: Province, Country, and Postal Code:

6. Primary Contact Phone Number:
Area Code
US

International

Country Code

City Code

0117. Primary Contact E-mail Address (use as many spaces as needed up to 60):

7. Primary contact E-mail Address.
(optional)

(over)

For side 2 please fill in
Employer Identification Number (EIN)

(continued)

EIN:

Payment Information
8. Payment Method. Choose the
payment method(s) by placing an “X” in
the box(es). The options available
are: EFTPS using the Internet or
phone and EFTPS through a Financial
Institution. Both EFTPS input methods
are interchangeable: Internet and phone.

8. Payment Method
EFTPS (by Internet and/or phone): check here if you will instruct EFTPS to transfer payment from your account.
EFTPS (through a Financial Institution): check here if you will instruct your financial institution to forward the payment to EFTPS.
You must check with your financial institution to determine if they are capable of providing this service.
NOTE: If you will only be using EFTPS through your Financial Institution as a payment method, skip to item #23.

✍

Note: For EFTPS (using the Internet or phone), complete the additional information required about your financial institution. Enrollment will automatically
enroll you for EFTPS through a Financial Institution as well as Same-Day Payment.
For EFTPS (through a Financial Institution), you initiate a tax payment through a financial institution. You must contact your financial institution to insure the
institution is capable of making an EFTPS payment through the Automated Clearing House (ACH) or a Same-Day Payment method. If you enroll for EFTPS through
a Financial Institution or Same-Day Payment, you may also enroll for EFTPS using the Internet or phone by providing the financial institution information
requested on items 19 through 23.

Tax Form Payment Amount Limits (EFTPS using the Internet or phone only)
9-18. Optional Tax Form Payment
Amount Limits (For EFTPS using the
Internet or phone only)

9.

This section is optional. You may set
amount limits for each tax type to
prevent an overpayment. The system will
compare your payment amount against
your stated limit and provide a warning if
you exceed the limit. You may override
the warning if you wish.

12.

720
943
15.

990PF
18.

1120
(19 through 24 must be completed if
EFTPS using the Internet or phone will
be used)

19. RTN:

20. Account Number. Enter the number
of the account you will use to pay your
taxes.

22. State:

22. State and ZIP Code. Use the twocharacter letter abbreviation for the state
your financial institution is located in and
indicate ZIP Code.
23. Authorization. This section authorizes
a Financial Agent of the U.S. Treasury to
initiate tax payments from the account(s)
you designate.
24. Taxpayer Signature. The taxpayer
must sign this section to authorize
participation in EFTPS. If there is no
signature, a form will be returned.
This section also provides authorization
to share the information provided with
your financial institution, required for the
processing of the Electronic Federal Tax
Payment System.
If signed by a corporate officer, partner,
or fiduciary on behalf of the taxpayer,
the signer certifies that they have the
authority to execute this authorization on
behalf of the taxpayer.

Remember to sign and mail your
enrollment form to the address on
reverse side.

$
$
$

10.

,

,

940
13.

,

,

945
16.

,

,

,

,

990T

$
$
$

11.

,

,

941
14.

,

,

990C
17.

,

,

1042

$
$
$

,

,

,

,

,

,

Financial Institution Information (to be completed if EFTPS using the Internet or phone will be used)

19. RTN. This is the nine-digit number
associated with your financial institution.
You may contact your financial institution
to verify this number.

21. Type. Please mark one box to indicate
whether the account is a checking or
savings account.

$

20. Account Number:

21. Type:
Checking
Savings

ZIP Code:

Authorization
23. For both payment methods: Please read the following Authorization Agreement:
I (as defined as the taxpayer whose signature is below) hereby authorize the contact person (listed in item #4 of this form) and the 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, and 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. If signed by a corporate officer, partner, or fiduciary on behalf of
the taxpayer, I certify that I have the authority to execute this authorization on behalf of the taxpayer. This authorization is to remain in full force and effect until
the designated Financial Agents of the U.S. Treasury have received notification from me of termination in such time and in such manner to afford a reasonable
opportunity to act on it.
Only EFTPS using the Internet or phone: Please read the following Authorization Agreement:
By completing the information in boxes 19-22 and signing below, I hereby 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
from me of termination in such time and in such manner as to afford a reasonable opportunity to act on it.
24. Taxpayer Signature

Date
Taxpayer Signature

Title
Print Name
Paperwork Reduction Act Notice: In accordance with the Paperwork Reduction Act of 1995, we ask for the information in the Electronic Federal Tax Payment System (EFTPS) Enrollment Form in order to carry out the requirements of 26 United
States Code 6001, 6011, and 6109. 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. Generally, tax returns and return information are confidential, as required by Code section 6103. This information is
used by the Internal Revenue Service to assure that payment(s) are properly credited to the appropriate account(s). Your response is mandatory if you are required by regulations to use Electronic Funds Transfer to make your Federal Tax Deposits.
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, Washington, DC 20224. Please do not send the enrollment form to this address.
The Privacy Act of 1974 requires that when we ask individuals for information about themselves, we state our legal right to ask for the information, why we are asking for the information, and how it will be used. We must also tell you what could
happen if we do not receive all or part of it, and whether your response is voluntary, required to obtain a benefit, or mandatory. Our legal right to ask for information is 5 U.S.C. 301 and Internal Revenue Code sections 6001, 6011, 6012, and
applicable regulations. The information will be used to enroll you in the Electronic Federal Tax Payment System (EFTPS). The information may not be disclosed except as provided by section 6103 of the Internal Revenue Code. We may give the
information to the Department of Justice and to other Federal agencies, as provided by law. We may also give it to cities, states, the District of Columbia, and U.S. commonwealths or possessions to carry out their laws. We may give it to foreign
governments because of tax treaties they have with the United States. Your response is mandatory if you are required by regulations to use electronic funds transfer to make your deposits. If you are not required by regulations to use electronic
funds transfer, your response is voluntary. If you do not provide all or part of the information, you may not be eligible to participate in the EFTPS. If you are required to use electronic funds transfer by regulation, you may be subject 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.

U.S. Government Printing Office:
Cat. No.: 21816U

Form 9779 (2/07)