Draft Form 14781 Electronic Federal Tax Payment System (EFTPS) – Insolven

Form

14781

(September 2016)

Department of the Treasury - Internal Revenue Service

OMB Number
1545-1467

Electronic Federal Tax Payment System (EFTPS) –
Insolvency Registration

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

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
on, 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 t required to use electronic funds
transfer to pay taxes owed, you need to pay the taxes due by another method.

This form can be mailed or sent via facsimile (see information at the top of this form.)

Catalog Number 69159Q

www.irs.gov

Form 14781 (9-2016)