9783 EFTPS Individual Enrollment Form

Ind Enrllmnt Form 9783

12/1/05

9:37 AM

Page 1

Tax Form 9783 with Instructions (OMB 1545-1467)

Department of the Treasury

Individual Enrollment Form for EFTPS –

This form contains instructions to complete the Electronic Federal Tax Payment System
(EFTPS) Enrollment Form for Individual 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

1-800-316-6541

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. Primary Taxpayer Identification
Number (SSN). Enter your nine-digit
Social Security Number. 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. Enter the SSN on the back of the
form in the upper right corner as well.
Sole Proprietor Businesses, without
employees; enroll as an Individual and
use your Social Security Number as your
Taxpayer Identification Number.
2. Taxpayer 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. Joint Filer Taxpayer Identification
Number (SSN). If this is a joint filing,
please provide the joint filer’s Social
Security Number.
4. Primary Taxpayer Address. This
address should be the address as it
appears on your tax return.

✍

Note: If the address 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.
5. Primary Taxpayer Phone Number.
Provide your area code and phone
number.
6. 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.
7-8. Primary Contact Mailing Address
and Phone Number (if different from #4
above). You need not complete the
address and phone section if your
contact’s address and phone is the same
as the primary taxpayer. If an address is
provided here, it will be used to mail
confirmation materials and instruction
booklets.

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.

MARKING EXAMPLE:

IA

5247 1

State

Zip Code

Taxpayer Information
1. Primary Taxpayer Identification Number (SSN) – (Please enter SSN on reverse side also):

2. Taxpayer(s) Name:

3. Joint Filer’s Taxpayer Identification Number (SSN):

4. Primary Taxpayer Address:

City:

State:

Zip Code:

International: Province, Country, and Postal Code:

5. Primary Taxpayer Phone Number:
Area Code
US

International

Country Code

City Code

011-

Contact Information
6. Primary Contact Name (if different from #2 above):

7. Primary Contact Mailing Street Address (if different from #4 above):

City:

State:

Zip Code:

International: Province, Country, and Postal Code:

8. Primary Contact Phone Number (if different from #5 above):
Area Code
US

International

Country Code

City Code

0119. Primary Contact E-mail Address (use as many spaces as needed up to 60):

9. Primary Contact E-mail Address.
(optional)

(over)

Ind Enrllmnt Form 9783

12/1/05

9:37 AM

Page 2

For side 2 please fill in
(continued)

Social Security Number (SSN)

SSN:

Payment Information
10. Payment Method. Check EFTPS as
your payment method if you will instruct
EFTPS to transfer payment from your
account. Both EFTPS input methods are
interchangeable: Internet and phone.

10. Payment Method
EFTPS (by Internet and/or phone): check here if you will instruct EFTPS to transfer payment from your account.
(You can interchange input payment methods: Internet and/or phone).

Tax Form Payment Amount Limit
11. Tax Form Payment Amount Limit
This section is optional. You may set an
amount limit for the 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. Routing Number (RTN). This is the
nine-digit number associated with your
financial institution. You may contact your
financial institution to verify this number.
13. Account Number. Enter the number
of the account you will use to pay your
taxes.
14. Type. Please mark one box to indicate
whether the account is a checking or
savings account.
15. Financial Institution State and Zip
Code. Use the two-character letter
abbreviation for the state your financial
institution is located in and indicate Zip
Code.
16. Authorization. This section authorizes
a Financial Agent of the U.S. Treasury to
initiate tax payments from the account(s)
you designate for EFTPS.
17. Taxpayer 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, required for the
processing of the Electronic Federal Tax
Payment System.
If signed on behalf of the individual
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.

11.

$

,

,

Financial Institution Information
12. RTN:

13. Account Number:

14. Type:
Checking
Savings

15. State:

Zip Code:

Authorization
16. Please read the following Authorization Agreement:
I (as defined by the taxpayer whose signature is below) hereby authorize the contact person (listed on this form in item #6) 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, 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 someone other than the taxpayer, I
certify that I have the authority (i.e., Form 2848 Power of Attorney and Declaration of Representative or other Power of Attorney) 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.
By completing the information in boxes 12-15 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.
17. Taxpayer Signature

Date
Taxpayer Signature
Print Name

Date
Joint Filer’s Signature
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. 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:
2006–321-822/02771
Cat. No.: 21820C

Form 9783 (7/05)