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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 www.EFTPS.gov 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.
1. Primary Taxpayer Identification Use only capital letters. Keep all printing within the boxes. IA 52471
Number (SSN). Enter your nine-digit
Social Security Number. If this enrollment • Do not make any stray marks on this form. State Zip Code
is for joint filers, enter the SSN of the Taxpayer Information
primary taxpayer. The primary taxpayer
is the taxpayer listed first on your tax 1. Primary Taxpayer Identification Number (SSN) – (Please enter SSN on reverse side also):
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.
2. Taxpayer Name(s). Print your name 3. Joint Filer’s Taxpayer Identification Number (SSN):
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.
3. Joint Filer Taxpayer Identification City: State: Zip Code:
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:SAMPLE
✍Note: If the address is incorrect, US Area Code International Country Code City Code
it can only be changed by submitting
an IRS Change of Address (Form 011-
8822) to the Internal Revenue
Service. The address on your EFTPS
enrollment will automatically be
updated when Form 8822 is submitted. Contact Information
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
name of a person, company, or third City: State: Zip Code:
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 US Area Code International Country Code City Code
address and phone section if your
contact’s address and phone is the same 011-
as the primary taxpayer. If an address is
provided here, it will be used to mail 9. Primary Contact E-mail Address (use as many spaces as needed up to 60):
confirmation materials and instruction
booklets.
9. Primary Contact E-mail Address.
(optional)
(over)
