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Department of the Treasury — Internal Revenue Service
Form 2159
(July 2018) Payroll Deduction Agreement
(See Instructions on the back of this page.)
TO: (Employer name and address) Regarding: (Taxpayer name and address)
Contact Person’s Name Telephone (Include area code) Social security or employer identification number
(Taxpayer) (Spouse, last four digits)
EMPLOYER — See the instructions on the back of Part 2. The taxpayer identified above Debit Payments Self-Identifier
on the right named you as an employer. Please read and sign the following statement to If you are unable to make electronic payments through a debit instrument
agree to withhold amount(s) from the taxpayer’s (employee’s) wages or salary to apply to (debit payments) by entering into a direct debit installment agreement please
taxes owed. check the box below:
I agree to participate in this payroll deduction agreement and will withhold the amount I am unable to make debit payments
shown below from each wage or salary payment due this employee. I will send the money Note: Not checking this box indicates that you are able but choosing not to
to the Internal Revenue Service every: (Check one box.) make debit payments. See Instructions to Taxpayer below for more details.
For assistance, call: 1-800-829-0115 (Business) or
WEEK TWO WEEKS MONTH OTHER (Specify.) 1-800-829-8374 (Individual – Self-Employed/Business Owners), or
1-800-829-0922 (Individuals – Wage Earners)
Signed:
Or write: Campus
Title: Date: (City, State, and ZIP Code)
Kinds of taxes (Form numbers) Tax Periods Amount owed as of
$ , plus all penalties and interest provided by law.
I am paid every (Check one): WEEK TWO WEEKS MONTH OTHER (Specify.)
I agree to have $ deducted from my wage or salary payments beginning until the total liability is paid in full. l also agree and
authorize this deduction to be increased or decreased as follows:
Date of increase (or decrease) Amount of Increase (or decrease) New installment payment amount
Terms of this agreement—By completing and submitting this agreement, you (the taxpayer) agree to the following terms:
• You will make each payment so that we (IRS) receive it by the monthly due • We will apply all payments on this agreement in the best interests of the
date stated on the front of this form. If you cannot make a scheduled United States. Generally we will apply the payment to the oldest collection
payment or accrue an additional liability, contact us immediately. statute, which is normally the oldest tax year or tax period.
• This agreement is based on your current financial condition. We may modify • We can terminate your installment agreement if: You do not make monthly
or terminate the agreement if our information shows that your ability to pay installment payments as agreed, you do not pay any other federal tax debt
has significantly changed. You must provide updated financial information when due, or you do not provide financial information when requested.
when requested. • If we terminate your agreement, we may collect the entire amount you owe by
• While this agreement is in effect, you must file all federal tax returns and pay levy on your income, bank accounts or other assets, or by seizing your
any (federal) taxes you owe on time. property. You will receive a notice from us prior to termination of your
agreement. EXCEPTION: We cannot collect the individual shared
• We will apply your federal tax refunds or overpayments (if any) to the amount responsibility payment under the Affordable Care Act by levy on your income
you owe until it is fully paid, including any shared responsibility payment or seizure.
under the Affordable Care Act. • We may terminate this agreement at any time if we find that collection of the
• You must pay a $225 user fee, which we have authority to deduct from your tax is in jeopardy.
first payment(s). You may be eligible for a reduced user fee of $43 that may • This agreement may require managerial approval. We'll notify you when we
be waived or reimbursed if certain conditions are met. See Form 13844 for approve or don’t approve the agreement.
qualifications and instructions. • We may file a Notice of Federal Tax lien if one has not been filed previously
• If you default on your installment agreement, you must pay a $89 which may negatively impact your credit rating, but we will not file a Notice of
reinstatement fee if we reinstate the agreement. We have the authority to Federal Tax Lien on an individual shared responsibility payment under the
deduct this fee from your first payment(s) after the agreement is reinstated. Affordable Care Act.
Additional Terms (To be completed by IRS) Note: Internal Revenue Service employees
may contact third parties in order to process
and maintain this agreement.
Your signature Title (If Corporate Officer or Partner) Date
Spouse’s signature (If a joint liability) Date
AGREEMENT LOCATOR NUMBER: Originator’s ID #: Originator Code:
Check the appropriate boxes: Name: Title:
RSI “1” no further review AI “0” Not a PPIA
A NOTICE OF FEDERAL TAX LIEN (Check one box.)
RSI “5” PPIA IMF 2 year review AI “1” Field Asset PPIA
RSI “6” PPIA BMF 2 year review AI “2” All other PPIAs HAS ALREADY BEEN FILED
Agreement Review Cycle: WILL BE FILED IMMEDIATELY
FOR IRS WILL BE FILED WHEN TAX IS ASSESSED
USE ONLY: Earliest CSED:
Check box if pre-assessed modules included MAY BE FILED IF THIS AGREEMENT DEFAULTS
Agreement examined or approved by (Signature, title, function) Date
Part 1 — Acknowledgement Copy (Return to IRS) Catalog No. 21475H www.irs.gov Form 2159 (Rev. 7-2018)
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