Fillable Form 9783 - Eftps Individual Enrollment Form (2005) printable pdf download

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:

EFTPS Customer Service

1-800-316-6541

For TDD (hearing impaired) support

1-800-733-4829

Visit our web site at

to enroll online. 24 hours a day, 7 days a week

en español

1-800-244-4829

EFTPS Enrollment Processing Center

When your form is completed, please mail to:

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.

Marking Instructions: • Use black or blue ink only.

MARKING EXAMPLE:

INSTRUCTIONS

• Please print legibly. Use one character per block.

I A

5 2 4 7 1

Use only capital letters. Keep all printing within the boxes.

1. Primary Taxpayer Identification

Number (SSN). Enter your nine-digit

• Do not make any stray marks on this form.

State

Zip Code

Social Security Number. If this enrollment

Taxpayer Information

is for joint filers, enter the SSN of the

primary taxpayer. The primary taxpayer

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

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

2. Taxpayer(s) Name:

employees; enroll as an Individual and

use your Social Security Number as your

Taxpayer Identification Number.

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

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

4. Primary Taxpayer Address:

primary taxpayer name first: JOHN AND

MARY SMITH, or JOHN SMITH AND

MARY JONES.

City:

State:

Zip Code:

3. Joint Filer Taxpayer Identification

Number (SSN). If this is a joint filing,

please provide the joint filer’s Social

Security Number.

International: Province, Country, and Postal Code:

4. Primary Taxpayer Address. This

address should be the address as it

appears on your tax return.

5. Primary Taxpayer Phone Number:

Area Code

Country Code

City Code

International

Note: If the address is incorrect,

it can only be changed by submitting

011-

an IRS Change of Address (Form

8822) to the Internal Revenue

Service. The address on your EFTPS

enrollment will automatically be

Contact Information

updated when Form 8822 is submitted.

See the back of Form 8822 to

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

determine where the form should be

mailed.

5. Primary Taxpayer Phone Number.

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

Provide your area code and phone

number.

6. Primary Contact Name. Print the

City:

State:

Zip Code:

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

International: Province, Country, and Postal Code:

be sent to your primary contact.

7-8. Primary Contact Mailing Address

and Phone Number (if different from #4

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

above). You need not complete the

Area Code

Country Code

City Code

International

address and phone section if your

011-

contact’s address and phone is the same

as the primary taxpayer. If an address is

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

provided here, it will be used to mail

confirmation materials and instruction

booklets.

9. Primary Contact E-mail Address.

(optional)

(over)

Form 9783 - Eftps Individual Enrollment Form (2005)

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