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

Form

14781

(December 2020)

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 send by facsimile to: Internal Revenue Service, Attn: Ricardo Perez, Fax number 855-536-3484.

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

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 (Rev. 12-2020)