Form 9783T EFTPS Individual Enrollment with Third Party Authorizati

Form 9783T with Instructions (OMB XXXX-XXXX)

Department of the Treasury

EFTPS Individual Enrollment with Third Party Authorization Form –

This is the Electronic Federal Tax Payment System
(EFTPS) Enrollment form for Individual Taxpayers who wish to authorize a Third Party to pay their federal taxes on their behalf. This disclosure authorization
allows third parties to effect enrollment of individuals in EFTPS, make electronic payments of income taxes on their behalf, answer inquiries about the payments,
and resolve issues related to EFTPS.

✍ Please provide the signed Form 9783T to your authorized Third Party who will retain the document.

FIELD DESCRIPTIONS
1. Primary Taxpayer Identification
Number (SSN). This is your nine-digit
Social Security Number.
2. Taxpayer Name(s). This is your name
exactly as it appears on the tax return.
3. Joint Filer Taxpayer Identification
Number (SSN). If this is a joint filing,
this is the joint filer’s Social Security
Number.

Taxpayer Information
1. Primary Taxpayer Identification Number (SSN):
2. Taxpayer(s) Name:
3. Joint Filer’s Taxpayer Identification Number (SSN):
4. Primary Taxpayer Address:
City:

4. Primary Taxpayer Address. Write
your address as it appears on your tax
return.

✍

Note: If the address does not
match the IRS records, you must
submit Form 8822, Change of Address
to the IRS before your enrollment can
be completed.
5. Third Party Name. This is the name
of the person, company, or Third Party
you are authorizing to make payments
on your behalf.
6-7. Third Party Mailing Address and
Phone Number. This is the contact
information for the authorized Third
Party.
If the Third Party is using a Master
Account to pay your taxes, Boxes 8 – 10
will be blank.
8. Routing Number (RTN). This is the
nine-digit number associated with your
financial institution if payments will be
made from your account.
9. Account Number. This is the number
of the account used to pay your taxes.
10. Type. This indicates whether the
account is a checking or savings account.
11. Authorization. This authorizes a Third
Party to enroll you in EFTPS and to make
income tax payments on your behalf. This
also authorizes a Financial Agent of the
U.S. Treasury to initiate tax payments
from the account designated.
12. Taxpayer Signature. The taxpayer
(and joint filer, if applicable) must sign this
section to authorize the Third Party to act
on their behalf. If there is no signature, the
Third Party Authorization is not valid.

✍

Note: Your signature indicates
that your Signature PIN, date of birth,
and prior year’s Adjusted Gross Income
were received by your Authorized Third
Party.
Remember to sign and return your
authorization form to the listed Third
Party.

State:

Zip Code:

International: Province, Country, and Postal Code:

Third Party Information
5. Third Party Name:

Batch Provider Registration Number:

6. Third Party Mailing Street Address:
City:

State:

Zip Code:

International: Province, Country, and Postal Code:
7. Third Party Phone Number:

Financial Institution Information
8. RTN:

9. Account Number:

10. Type:

❑ Checking

❑ Savings

Authorization
11. Please read the following Authorization Agreement:
I (as defined by the taxpayer signing this Authorization) hereby authorize the Third Party (listed above) 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 income taxes, and answer inquiries and resolve issues related to enrollment and income tax payments. This information includes, but it 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.
I have reviewed the information in items 1 – 10 above. I authorize the above-named Third Party Batch Provider to enter my self-selected PIN as my electronic
signature for this EFTPS Individual Enrollment and Third Party Authorization. Additionally, by signing, I authorize the designated Financial Agent of the U.S.
Treasury to initiate debit entries to the financial institution account indicated above for payment of Federal income taxes owed to the IRS upon request by
Taxpayer or his/her representative, using the Electronic Federal Tax Payment System (EFTPS). All debits initiated by the U.S. Treasury designated Financial Agent
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 Agent of the U.S. Treasury has received written notification from me of
termination in such time and in such manner as to afford a reasonable opportunity to act on it.
12. Taxpayer Signature:

Date:

Print Name:
Joint Filer’s Signature:

Date:

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.

9/21/06