1220 Form 14781 (PDF)

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f14781.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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(December 2020)

Department of the Treasury - Internal Revenue Service

OMB Number

1545-1467

For questions or more information please call EFTPS Provider Help Desk at 1-866-553-9413.

When your form is completed, please send by facsimile to : Internal Revenue Service, Attn: Ricardo Perez, Fax number 855-536-3484.

Trustee Information

1. Trustee Taxpayer Identification Number (TIN) (enter your Trustee nine-digit Employer Identification Number, without dashes)

2. Trustee name (print/type) (the only valid characters are A-Z, 0-9, -, &, and blank)

3. Trustee address (print/type your mailing address)

City State ZIP code

–

Contact Information

4. Primary contact name (print/type the name of a person who can be contacted in the event questions arise regarding this form)

Primary contact email address

Software Vendor & Bank Information

Primary contact telephone number

Area code

.

Software Vendor and Bank Name (print/type name vendor and phone number of your software, and name of your bank)

5. Software vendor name Software vendor telephone number

Area code

Bank name

Trustee Signature

The registration from must be signed to authorize participation in the EFTPS program.

6. If signed by a Corporate Officer, Partner, or Fiduciary on behalf of the trustee, he/she certifies that the undersigned has the authority to execute this authorization on behalf of the trustee

SIGN

Authorized signature Date

Name (print/type) Title

This form can be mailed or sent via facsimile (see information at the top of this form.)

Catalog Number 69159Q www.irs.gov Form 14781 (Rev. 12-2020)