Federal Free Printable Form 2159 (Rev. 1-2015) for 2017 Federal Payroll Deduction Agreement

It appears you don't have a PDF plugin for this browser. Please use the link below to download 2016-federal-form-2159.pdf, and you can print it directly from your computer.

Payroll Deduction Agreement
Form 2159 (Rev. 1-2015)

Form 2159 Department of the Treasury — Internal Revenue Service Payroll Deduction Agreement (Rev. January 2015) (See Instructions on the back of this page.) Regarding: (Taxpayer name and address) TO: (Employer name and address) Contact Person’s Name Social security or employer identification number Telephone (Include area code) (Taxpayer) 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 TWO WEEKS MONTH (Spouse, last four digits) Your telephone number (Include area code) (Home) (Work or business) 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: OTHER (Specify.) Campus (City, State, and ZIP Code) Financial Institution(s) (Name and address) Signed: Title: Date: Kinds of taxes (Form numbers) I am paid every (Check one): Tax Periods WEEK I agree to have $ TWO WEEKS Amount owed as of $ , plus all penalties and interest provided by law. MONTH OTHER (Specify.) 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 date stated on the front of this form. If you cannot make a scheduled payment, contact us immediately. • This agreement is based on your current financial condition. We may modify or terminate the agreement if our information shows that your ability to pay has significantly changed. You must provide updated financial information when requested. • While this agreement is in effect, you must file all federal tax returns and pay any (federal) taxes you owe on time. • We will apply your federal tax refunds or overpayments (if any) to the amount you owe until it is fully paid, including any shared responsibility payment under the Affordable Care Act. • You must pay a $120 user fee, which we have authority to deduct from your first payment(s). You may be eligible for a reduced user fee of $43. See Form 13844 for qualifications and instructions. • If you default on your installment agreement, you must pay a $50 reinstatement fee if we reinstate the agreement. We have the authority to deduct this fee from your first payment(s) after the agreement is reinstated. • We will apply all payments on this agreement in the best interests of the United States. Generally we will apply the payment to the oldest collection statute, which is normally the oldest tax year or tax period. • We can terminate your installment agreement if: You do not make monthly installment payments as agreed, you do not pay any other federal tax debt when due, or you do not provide financial information when requested. • If we terminate your agreement, we may collect the entire amount you owe by levy on your income, bank accounts or other assets, or by seizing your property. You will receive a notice from us prior to termination of your agreement. EXCEPTION: We cannot collect the individual shared responsibility payment under the Affordable Care Act by levy on your income or seizure. • We may terminate this agreement at any time if we find that collection of the tax is in jeopardy. • This agreement may require managerial approval. We'll notify you when we approve or don’t approve the agreement. • We may file a Notice of Federal Tax lien if one has not been filed previously which may negatively impact your credit rating, but we will not file a Notice of Federal Tax Lien on an individual shared responsibility payment under the 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) FOR IRS USE ONLY: AGREEMENT LOCATOR NUMBER: Check the appropriate boxes: RSI “1” no further review Date Originator’s ID #: Originator Code: Name: Title: AI “0” Not a PPIA RSI “5” PPIA IMF 2 year review AI “1” Field Asset PPIA RSI “6” PPIA BMF 2 year review AI “2” All other PPIAs A NOTICE OF FEDERAL TAX LIEN (Check one box.) HAS ALREADY BEEN FILED WILL BE FILED IMMEDIATELY Agreement Review Cycle: Earliest CSED: Check box if pre-assessed modules included WILL BE FILED WHEN TAX IS ASSESSED MAY BE FILED IF THIS AGREEMENT DEFAULTS Agreement examined or approved by (Signature, title, function) Part 1 — Acknowledgement Copy (Return to IRS) Date Catalog No. 21475H Reset Form Fields www.irs.gov Form 2159 (Rev. 1-2015) Form 2159 Department of the Treasury — Internal Revenue Service Payroll Deduction Agreement (Rev. January 2015) (See Instructions on the back of this page.) Regarding: (Taxpayer name and address) TO: (Employer name and address) Contact Person’s Name Social security or employer identification number Telephone (Include area code) (Taxpayer) 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 TWO WEEKS MONTH (Spouse, last four digits) Your telephone number (Include area code) (Home) (Work or business) 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: OTHER (Specify.) Campus (City, State, and ZIP Code) Financial Institution(s) (Name and address) Signed: Title: Date: Kinds of taxes (Form numbers) I am paid every (Check one): Tax Periods WEEK I agree to have $ TWO WEEKS Amount owed as of $ , plus all penalties and interest provided by law. MONTH OTHER (Specify.) 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 date stated on the front of this form. If you cannot make a scheduled payment, contact us immediately. • This agreement is based on your current financial condition. We may modify or terminate the agreement if our information shows that your ability to pay has significantly changed. You must provide updated financial information when requested. • While this agreement is in effect, you must file all federal tax returns and pay any (federal) taxes you owe on time. • We will apply your federal tax refunds or overpayments (if any) to the amount you owe until it is fully paid, including any shared responsibility payment under the Affordable Care Act. • You must pay a $120 user fee, which we have authority to deduct from your first payment(s). You may be eligible for a reduced user fee of $43. See Form 13844 for qualifications and instructions. • If you default on your installment agreement, you must pay a $50 reinstatement fee if we reinstate the agreement. We have the authority to deduct this fee from your first payment(s) after the agreement is reinstated. • We will apply all payments on this agreement in the best interests of the United States. Generally we will apply the payment to the oldest collection statute, which is normally the oldest tax year or tax period. • We can terminate your installment agreement if: You do not make monthly installment payments as agreed, you do not pay any other federal tax debt when due, or you do not provide financial information when requested. • If we terminate your agreement, we may collect the entire amount you owe by levy on your income, bank accounts or other assets, or by seizing your property. You will receive a notice from us prior to termination of your agreement. EXCEPTION: We cannot collect the individual shared responsibility payment under the Affordable Care Act by levy on your income or seizure. • We may terminate this agreement at any time if we find that collection of the tax is in jeopardy. • This agreement may require managerial approval. We'll notify you when we approve or don’t approve the agreement. • We may file a Notice of Federal Tax lien if one has not been filed previously which may negatively impact your credit rating, but we will not file a Notice of Federal Tax Lien on an individual shared responsibility payment under the 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) FOR IRS USE ONLY: AGREEMENT LOCATOR NUMBER: Check the appropriate boxes: RSI “1” no further review Date Originator’s ID #: Originator Code: Name: Title: AI “0” Not a PPIA RSI “5” PPIA IMF 2 year review AI “1” Field Asset PPIA RSI “6” PPIA BMF 2 year review AI “2” All other PPIAs A NOTICE OF FEDERAL TAX LIEN (Check one box.) HAS ALREADY BEEN FILED WILL BE FILED IMMEDIATELY Agreement Review Cycle: Earliest CSED: Check box if pre-assessed modules included WILL BE FILED WHEN TAX IS ASSESSED MAY BE FILED IF THIS AGREEMENT DEFAULTS Agreement examined or approved by (Signature, title, function) Part 2 — Employer’s Copy Catalog No. 21475H Date www.irs.gov Form 2159 (Rev. 1-2015) INSTRUCTIONS TO EMPLOYER This payroll deduction agreement is subject to 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 all parts of the form, please return the parts of the form which were requested on the letter the employee received with the form. 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 www.irs.gov Form 2159 (Rev. 1-2015) Form 2159 Department of the Treasury — Internal Revenue Service Payroll Deduction Agreement (Rev. January 2015) (See Instructions on the back of this page.) Regarding: (Taxpayer name and address) TO: (Employer name and address) Contact Person’s Name Social security or employer identification number Telephone (Include area code) (Taxpayer) 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 TWO WEEKS MONTH (Spouse, last four digits) Your telephone number (Include area code) (Home) (Work or business) 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: OTHER (Specify.) Campus (City, State, and ZIP Code) Financial Institution(s) (Name and address) Signed: Title: Date: Kinds of taxes (Form numbers) I am paid every (Check one): Tax Periods WEEK I agree to have $ TWO WEEKS Amount owed as of $ , plus all penalties and interest provided by law. MONTH OTHER (Specify.) 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 date stated on the front of this form. If you cannot make a scheduled payment, contact us immediately. • This agreement is based on your current financial condition. We may modify or terminate the agreement if our information shows that your ability to pay has significantly changed. You must provide updated financial information when requested. • While this agreement is in effect, you must file all federal tax returns and pay any (federal) taxes you owe on time. • We will apply your federal tax refunds or overpayments (if any) to the amount you owe until it is fully paid, including any shared responsibility payment under the Affordable Care Act. • You must pay a $120 user fee, which we have authority to deduct from your first payment(s). You may be eligible for a reduced user fee of $43. See Form 13844 for qualifications and instructions. • If you default on your installment agreement, you must pay a $50 reinstatement fee if we reinstate the agreement. We have the authority to deduct this fee from your first payment(s) after the agreement is reinstated. • We will apply all payments on this agreement in the best interests of the United States. Generally we will apply the payment to the oldest collection statute, which is normally the oldest tax year or tax period. • We can terminate your installment agreement if: You do not make monthly installment payments as agreed, you do not pay any other federal tax debt when due, or you do not provide financial information when requested. • If we terminate your agreement, we may collect the entire amount you owe by levy on your income, bank accounts or other assets, or by seizing your property. You will receive a notice from us prior to termination of your agreement. EXCEPTION: We cannot collect the individual shared responsibility payment under the Affordable Care Act by levy on your income or seizure. • We may terminate this agreement at any time if we find that collection of the tax is in jeopardy. • This agreement may require managerial approval. We'll notify you when we approve or don’t approve the agreement. • We may file a Notice of Federal Tax lien if one has not been filed previously which may negatively impact your credit rating, but we will not file a Notice of Federal Tax Lien on an individual shared responsibility payment under the 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) FOR IRS USE ONLY: AGREEMENT LOCATOR NUMBER: Check the appropriate boxes: RSI “1” no further review Date Originator’s ID #: Originator Code: Name: Title: AI “0” Not a PPIA RSI “5” PPIA IMF 2 year review AI “1” Field Asset PPIA RSI “6” PPIA BMF 2 year review AI “2” All other PPIAs A NOTICE OF FEDERAL TAX LIEN (Check one box.) HAS ALREADY BEEN FILED WILL BE FILED IMMEDIATELY Agreement Review Cycle: Earliest CSED: Check box if pre-assessed modules included WILL BE FILED WHEN TAX IS ASSESSED MAY BE FILED IF THIS AGREEMENT DEFAULTS Agreement examined or approved by (Signature, title, function) Part 3 — Taxpayer’s Copy Catalog No. 21475H Date www.irs.gov Form 2159 (Rev. 1-2015) 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 the last four digits of 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, your employer should return the parts of the form which were requested on your letter or return Part 1 of the form to 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 www.irs.gov Form 2159 (Rev. 1-2015)
Extracted from PDF file 2016-federal-form-2159.pdf, last modified December 2014

More about the Federal Form 2159 Other TY 2016

We last updated the Payroll Deduction Agreement in May 2017, so this is the latest version of Form 2159, fully updated for tax year 2016. You can download or print current or past-year PDFs of Form 2159 directly from TaxFormFinder. You can print other Federal tax forms here.

Other Federal Other Forms:

TaxFormFinder has an additional 774 Federal income tax forms that you may need, plus all federal income tax forms.

Form Code Form Name
Form 8962 Premium Tax Credit
Form 12277 Application for Withdrawal of Filed Form 668(Y), Notice of Federal Tax Lien (Internal Revenue Code Section 6323(j))
Form 13844 Application For Reduced User Fee For Installment Agreements
Form 8283 Noncash Charitable Contributions
Form W-4V Voluntary Withholding Request

Download all  tax forms View all 775 Federal Income Tax Forms


Form Sources:

The Internal Revenue Service usually releases income tax forms for the current tax year between October and January, although changes to some forms can come even later. We last updated Federal Form 2159 from the Internal Revenue Service in May 2017.

Show Sources >

Historical Past-Year Versions of Federal Form 2159

We have a total of four past-year versions of Form 2159 in the TaxFormFinder archives, including for the previous tax year. Download past year versions of this tax form as PDFs here:


2016 Form 2159

Form 2159 (Rev. 1-2015)

Payroll Deduction Agreement 2015 Form 2159

Form 2159 (Rev. 1-2015)

Payroll Deduction Agreement 2012 Form 2159

Form 2159 (Rev. 1-2007)

Payroll Deduction Agreement 2011 Form 2159

Form 2159 (Rev. 1-2007)


TaxFormFinder Disclaimer:

While we do our best to keep our list of Federal Income Tax Forms up to date and complete, we cannot be held liable for errors or omissions. Is the form on this page out-of-date or not working? Please let us know and we will fix it ASAP.

** This Document Provided By TaxFormFinder.org **
Source: http://www.taxformfinder.org/federal/form-2159