Form 2159
(Rev. January 2007)
TO: (Employer name and address)
Department of the Treasury — Internal Revenue Service
Payroll Deduction Agreement
(See Instructions on the back of this page.)
Regarding: (Taxpayer name and address)
Contact Person’s Name
EMPLOYER—See the instructions on the back of Part 2. The taxpayer identified
above on the right named you as an employer. Please read and sign the
following statement to agree to withhold amount(s) from the taxpayer’s
(employee’s) wages or salary to apply to taxes owed.
I agree to participate in this payroll deduction agreement and will withhold the
amount shown below from each wage or salary payment due this employee.
I will send the money to the Internal Revenue Service every: (Check one box.)
WEEK
Signed:
Title:
Kinds of taxes (Form numbers)
I am paid every: (Check one):
I agree to have $
deducted from my wage or salary payment beginning
authorize this deduction to be increased or decreased as follows:
Date of increase (or decrease)
Telephone (Include area code)
TWO WEEKS
MONTH
OTHER (Specify.)
Social security or employer identification number
(Taxpayer)
Your telephone number (Include area code)
(Home)
For assistance, call: 1-800-829-0115 (Business) or
1-800-829-8374 (Individual – Self-Employed/Business Owners), or
1-800-829-0922 (Individuals – Wage Earners)
Or write:
(City, State, and ZIP Code)
Financial Institution(s) (Name and address)
(Spouse)
(Work or business)
Campus
Date:
WEEK
Tax Periods
TWO WEEKS
MONTH
Amount owed as of
$
, plus all penalties and interest provided by law.
OTHER (Specify.)
until the total liability is paid in full. l also agree and
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:
authority to deduct this fee from your first payment(s) after the
You will make each payment so that we (IRS) receive it by the
agreement is reinstated.
monthly due date stated on the front of this form. If you cannot make
a scheduled payment, contact us immediately.
We will apply all payments on this agreement in the best interests
of the United States.
This agreement is based on your current financial condition. We
may modify or terminate the agreement if our information shows
We can terminate your installment agreement if:
that your ability to pay has significantly changed. You must provide
You do not make monthly installment payments as agreed.
updated financial information when requested.
You do not pay any other federal tax debt when due.
While this agreement is in effect, you must file all federal tax
You do not provide financial information when requested.
returns and pay any (federal) taxes you owe on time.
If we terminate your agreement, we may collect the entire amount
you owe by levy on your income, bank accounts or other assets, or
We will apply your federal tax refunds or overpayments (if any) to
by seizing your property.
the amount you owe until it is fully paid.
You must pay a $105 user fee, which we have authority to deduct
We may terminate this agreement at any time if we find that
from your first payment(s).
collection of the tax is in jeopardy.
If you default on your installment agreement, you must pay a $45
This agreement may require managerial approval. We'll notify you
reinstatement fee if we reinstate the agreement. We have the
when we approve or don’t approve the agreement.
•
•
•
•
•
•
Additional Terms (To be completed by IRS)
Your signature
Spouse’s signature (If a joint liability)
Agreement examined or approved by (Signature, title, function)
FOR IRS USE ONLY
AGREEMENT LOCATOR NUMBER:
Check the appropriate boxes:
AI “0” Not a PPIA
RSI “1” no further review
AI “1” Field Asset PPIA
RSI “5” PPIA IMF 2 year review
AI “2” All other PPIAs
RSI “6” PPIA BMF 2 year review
Agreement Review Cycle:
Earliest CSED:
Check box if pre-assessed modules included
FOR IRS
USE ONLY:
•
• •
•
•
•
•
•
Title (If Corporate Officer or Partner)
Note: Internal Revenue Service employees
may contact third parties in order to process
and maintain this agreement.
Date
Date
Date
Originator’s ID #:
Name:
A NOTICE OF FEDERAL TAX LIEN (Check one box.)
HAS ALREADY BEEN FILED
WILL BE FILED IMMEDIATELY
WILL BE FILED WHEN TAX IS ASSESSED
MAY BE FILED IF THIS AGREEMENT DEFAULTS
Originator Code:
Title:
Part 1— Acknowledgement Copy (Return to IRS)
Catalog No. 21475H
Reset Form Fields
www.irs.gov
Form 2159 (Rev. 1-2007)
XX Position (the first two numbers) denotes either the Initiator or Type of Agreement. The XX values are:
Agreement Locator Number Designations
00
01
02
03
06
07
08
11
12
20
90
91
92
99
Form 433-D initiated by AO on an ACS case
Service Center and Toll-free initiated agreements
AO Field Territory (revenue officer) initiated agreements
Direct Debit agreements initiated by any function
Exam initiated agreements
Submission Processing initiated agreements
Agreements initiated by other functions
Form 2159 agreement initiated by AO or ACS
AO or ACS agreement with multiple conditions
Status 22/24 accounts – Call Site/SCCB
SCCB initiated agreements – other than status 22 or 26
Form 2159 agreement initiated by SCCB
SCCB agreement with multiple conditions
Up to 120 days extensions
YY Position (the second two numbers) denotes Conditions Affecting the Agreement. The YY values are:
08
09
12
15
27
32
36
41
53
63
66
70
80
99
Continuous Wage Levy (from ACS and RO)
All other conditions
One year rule (use for specific BAL DUE module agreements)
In Business Trust Fund (IBTF) monitoring required
Restricted Interest/Penalty condition present
Unassessed modules to be included in agreement
Streamlined agreements, less than 60 months, up to $25,000
BMF in Business Deferral Level (SCCB USE ONLY)
Report Currently Not Collectible (CNC) if agreement defaults
Cross-reference TIN (Status 63)
File lien in event of default
Secondary TP responsible for Joint Liability
Review and revise payment amount
Up to 120 days extensions
When an agreement has more than one condition, use either 12 or 92 in the “XX” position and assign the primary condition
(YY) based on the following priorities:
The remaining multiple conditions will be input as a history item on IDRS by SCCB. For example, to construct a history item to
record an unassessed module, use the following format:
#1-53, #2-08, #3-27, or #4-15
UM309312 (Unassessed module, MFT 30, 9312 Tax Period); or
UMFILE LIEN (Unassessed module, file Lien, if appropriate)
Installment Agreement Originator Codes
20
21
30
31
50
51
58
59
60
61
70
71
72
73
74
75
76
77
78
80
81
90-91
Collection field function regular agreement
Collection field function streamlined agreement
Reserved
Reserved
Field assistance regular agreement
Field assistance streamlined agreement
Field Assistance ICS – regular agreement
Field Assistance ICS – streamlined agreement
Examination regular agreement
Examination streamlined agreement
Toll-free regular agreement
Toll-free streamlined agreement
Paper regular agreement
Paper streamlined agreement
Voice Response Unit (system generated)
Automated Collection Branch regular
Automated Collection Branch streamlined
Automated Collection Branch Voice Response Unit regular (system generated)
Automated Collection Branch Voice Response Unit streamlined (system generated)
Other function regular agreement
Other function-streamlined agreement
Reserved for vendors – all streamlined agreements
Catalog No. 21475H
Form 2159 (Rev. 1-2007)
Form 2159
(Rev. January 2007)
TO: (Employer name and address)
Department of the Treasury — Internal Revenue Service
Payroll Deduction Agreement
(See Instructions on the back of this page.)
Regarding: (Taxpayer name and address)
Contact Person’s Name
EMPLOYER—See the instructions on the back of Part 2. The taxpayer identified
above on the right named you as an employer. Please read and sign the
following statement to agree to withhold amount(s) from the taxpayer’s
(employee’s) wages or salary to apply to taxes owed.
I agree to participate in this payroll deduction agreement and will withhold the
amount shown below from each wage or salary payment due this employee.
I will send the money to the Internal Revenue Service every: (Check one box.)
WEEK
Signed:
Title:
Kinds of taxes (Form numbers)
I am paid every: (Check one):
I agree to have $
deducted from my wage or salary payment beginning
authorize this deduction to be increased or decreased as follows:
Date of increase (or decrease)
Telephone (Include area code)
TWO WEEKS
MONTH
OTHER (Specify.)
Social security or employer identification number
(Taxpayer)
Your telephone number (Include area code)
(Home)
For assistance, call: 1-800-829-0115 (Business) or
1-800-829-8374 (Individual – Self-Employed/Business Owners), or
1-800-829-0922 (Individuals – Wage Earners)
Or write:
(City, State, and ZIP Code)
Financial Institution(s) (Name and address)
(Spouse)
(Work or business)
Campus
Date:
WEEK
Tax Periods
TWO WEEKS
MONTH
Amount owed as of
$
, plus all penalties and interest provided by law.
OTHER (Specify.)
until the total liability is paid in full. l also agree and
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
authority to deduct this fee from your first payment(s) after the
agreement is reinstated.
monthly due date stated on the front of this form. If you cannot make
a scheduled payment, contact us immediately.
We will apply all payments on this agreement in the best interests
of the United States.
This agreement is based on your current financial condition. We
may modify or terminate the agreement if our information shows
We can terminate your installment agreement if:
that your ability to pay has significantly changed. You must provide
You do not make monthly installment payments as agreed.
updated financial information when requested.
You do not pay any other federal tax debt when due.
While this agreement is in effect, you must file all federal tax
You do not provide financial information when requested.
returns and pay any (federal) taxes you owe on time.
If we terminate your agreement, we may collect the entire amount
you owe by levy on your income, bank accounts or other assets, or
We will apply your federal tax refunds or overpayments (if any) to
by seizing your property.
the amount you owe until it is fully paid.
You must pay a $105 user fee, which we have authority to deduct
We may terminate this agreement at any time if we find that
from your first payment(s).
collection of the tax is in jeopardy.
If you default on your installment agreement, you must pay a $45
This agreement may require managerial approval. We'll notify you
reinstatement fee if we reinstate the agreement. We have the
when we approve or don’t approve the agreement.
•
•
•
•
•
•
Additional Terms (To be completed by IRS)
Your signature
Spouse’s signature (If a joint liability)
Agreement examined or approved by (Signature, title, function)
FOR IRS USE ONLY
AGREEMENT LOCATOR NUMBER:
Check the appropriate boxes:
AI “0” Not a PPIA
RSI “1” no further review
AI “1” Field Asset PPIA
RSI “5” PPIA IMF 2 year review
AI “2” All other PPIAs
RSI “6” PPIA BMF 2 year review
Agreement Review Cycle:
Earliest CSED:
Check box if pre-assessed modules included
FOR IRS
USE ONLY:
•
• •
•
•
•
•
•
Title (If Corporate Officer or Partner)
Note: Internal Revenue Service employees
may contact third parties in order to process
and maintain this agreement.
Date
Date
Date
Originator’s ID #:
Name:
A NOTICE OF FEDERAL TAX LIEN (Check one box.)
HAS ALREADY BEEN FILED
WILL BE FILED IMMEDIATELY
WILL BE FILED WHEN TAX IS ASSESSED
MAY BE FILED IF THIS AGREEMENT DEFAULTS
Originator Code:
Title:
Part 2 — Employer’s Copy
Catalog No. 21475H
www.irs.gov
Form 2159 (Rev. 1-2007)
INSTRUCTIONS TO EMPLOYER
This payroll deduction agreement requires your approval. If you agree to participate,
please complete the spaces provided under the employer section on the front of this form.
WHAT YOU SHOULD DO
•
Enter the name and telephone number of a contact person. (This will allow us
to contact you if your employee’s liability is satisfied ahead of time.)
•
•
•
Indicate when you will forward payments to IRS.
Sign and date the form.
After you and your employee have completed and signed the form, please
return it (all parts) to IRS. Use the IRS address on the letter the employee
received with the form or the address shown on the front of the form.
HOW TO MAKE PAYMENTS
Please deduct the amount your employee agreed with the IRS to have
deducted from each wage or salary payment due the employee.
Make your check payable to the “United States Treasury.” To insure
proper credit, please write your employee’s name and social security
number on each payment.
Send the money to the IRS mailing address printed on the letter that came
with the agreement. Your employee should give you a copy of this letter. If
there is no letter, use the IRS address shown on the front of the form.
Note: The amount of the liability shown on the form may not include all penalties and
interest provided by law. Please continue to make payments unless IRS notifies you
that the liability has been satisfied. When the amount owed, as shown on the form, is
paid in full and IRS hasn’t notified you that the liability has been satisfied, please call
the appropriate telephone number below to request the final balance due.
If you need assistance, please call the telephone number on the letter that came with
the agreement or write to the address shown on the letter. If there’s no letter, please
call the appropriate telephone number below or write IRS at the address shown on
the front of the form.
For assistance, call: 1-800-829-0115 (Business), or
1-800-829-8374 (Individual – Self-Employed/Business Owners), or
1-800-829-0922 (Individuals – Wage Earners)
THANK YOU FOR YOUR COOPERATION
Catalog No. 21475H
Form 2159 (Rev. 1-2007)
Form 2159
(Rev. January 2007)
TO: (Employer name and address)
Department of the Treasury — Internal Revenue Service
Payroll Deduction Agreement
(See Instructions on the back of this page.)
Regarding: (Taxpayer name and address)
Contact Person’s Name
EMPLOYER—See the instructions on the back of Part 2. The taxpayer identified
above on the right named you as an employer. Please read and sign the
following statement to agree to withhold amount(s) from the taxpayer’s
(employee’s) wages or salary to apply to taxes owed.
I agree to participate in this payroll deduction agreement and will withhold the
amount shown below from each wage or salary payment due this employee.
I will send the money to the Internal Revenue Service every: (Check one box.)
WEEK
Signed:
Title:
Kinds of taxes (Form numbers)
I am paid every: (Check one):
I agree to have $
deducted from my wage or salary payment beginning
authorize this deduction to be increased or decreased as follows:
Date of increase (or decrease)
Telephone (Include area code)
TWO WEEKS
MONTH
OTHER (Specify.)
Social security or employer identification number
(Taxpayer)
Your telephone number (Include area code)
(Home)
For assistance, call: 1-800-829-0115 (Business) or
1-800-829-8374 (Individual – Self-Employed/Business Owners), or
1-800-829-0922 (Individuals – Wage Earners)
Or write:
(City, State, and ZIP Code)
Financial Institution(s) (Name and address)
(Spouse)
(Work or business)
Campus
Date:
WEEK
Tax Periods
TWO WEEKS
MONTH
Amount owed as of
$
, plus all penalties and interest provided by law.
OTHER (Specify.)
until the total liability is paid in full. l also agree and
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
authority to deduct this fee from your first payment(s) after the
agreement is reinstated.
monthly due date stated on the front of this form. If you cannot make
a scheduled payment, contact us immediately.
We will apply all payments on this agreement in the best interests
of the United States.
This agreement is based on your current financial condition. We
may modify or terminate the agreement if our information shows
We can terminate your installment agreement if:
that your ability to pay has significantly changed. You must provide
You do not make monthly installment payments as agreed.
updated financial information when requested.
You do not pay any other federal tax debt when due.
While this agreement is in effect, you must file all federal tax
You do not provide financial information when requested.
returns and pay any (federal) taxes you owe on time.
If we terminate your agreement, we may collect the entire amount
you owe by levy on your income, bank accounts or other assets, or
We will apply your federal tax refunds or overpayments (if any) to
by seizing your property.
the amount you owe until it is fully paid.
You must pay a $105 user fee, which we have authority to deduct
We may terminate this agreement at any time if we find that
from your first payment(s).
collection of the tax is in jeopardy.
If you default on your installment agreement, you must pay a $45
This agreement may require managerial approval. We'll notify you
reinstatement fee if we reinstate the agreement. We have the
when we approve or don’t approve the agreement.
•
•
•
•
•
•
Additional Terms (To be completed by IRS)
Your signature
Spouse’s signature (If a joint liability)
Agreement examined or approved by (Signature, title, function)
FOR IRS USE ONLY
AGREEMENT LOCATOR NUMBER:
Check the appropriate boxes:
AI “0” Not a PPIA
RSI “1” no further review
AI “1” Field Asset PPIA
RSI “5” PPIA IMF 2 year review
AI “2” All other PPIAs
RSI “6” PPIA BMF 2 year review
Agreement Review Cycle:
Earliest CSED:
Check box if pre-assessed modules included
FOR IRS
USE ONLY:
•
• •
•
•
•
•
•
Title (If Corporate Officer or Partner)
Note: Internal Revenue Service employees
may contact third parties in order to process
and maintain this agreement.
Date
Date
Date
Originator’s ID #:
Name:
A NOTICE OF FEDERAL TAX LIEN (Check one box.)
HAS ALREADY BEEN FILED
WILL BE FILED IMMEDIATELY
WILL BE FILED WHEN TAX IS ASSESSED
MAY BE FILED IF THIS AGREEMENT DEFAULTS
Originator Code:
Title:
Part 3 — Taxpayer’s Copy
Catalog No. 21475H
www.irs.gov
Form 2159 (Rev. 1-2007)
INSTRUCTIONS TO TAXPAYER
If not already completed by an IRS employee, please fill in the information in the
spaces provided on the front of this form for the following items:
•
•
Your employer’s name and address
Your name(s) (plus spouse’s name if the amount owed is for a joint return) and current
address.
•
Your social security number or employer identification number. (Use the
number that appears on the notice(s) you received.) Also, enter your spouse’s
social security number if this is a joint liability.
•
•
•
•
•
•
•
•
Your home and work telephone number(s)
The complete name and address of your financial institution(s)
The kind of taxes you owe (form numbers) and the tax periods
The amount you owe as of the date you spoke to IRS
When you are paid
The amount you agreed to have deducted from your pay when you spoke to IRS
The date the deduction is to begin
The amount of any increase or decrease in the deduction amount, if you
agreed to this with IRS; otherwise, leave BLANK
After you complete, sign (along with your spouse if this is a joint liability), and date
this agreement form, give it to your participating employer. If you received the
form by mail, please give the employer a copy of the letter that came with it.
Your employer should mark the payment frequency on the form and sign it. Then
the employer should return all parts of the form to the IRS address on your letter
or the address shown in the “For assistance” box on the front of the form.
If you need assistance, please call the appropriate telephone number below or
write IRS at the address shown on the form. However, if you received this
agreement by mail, please call the telephone number on the letter that came with
it or write IRS at the address shown on the letter.
For assistance, call: 1-800-829-0115 (Business), or
1-800-829-8374 (Individual – Self-Employed/Business Owners), or
1-800-829-0922 (Individuals – Wage Earners)
Note: This agreement will not affect your liability (if any) for backup withholding under
Public Law 98-67, the Interest and Dividend Compliance Act of 1983.
Catalog No. 21475H
Form 2159 (Rev. 1-2007)