EFTPS Primary Contact Information Change Form

P RIMARY C ONTACT I NFORMATION C HANGE F ORM
Fax to: 866-568-2490
INSTRUCTIONS:
Primary Contact Name. Please fill in the name of the previous contact and the name of the new contact to whom future confirmations will be sent.
Primary Contact Address. Please fill in the previous information and new information updates to the street address, city, state, zip code, and province,country,
and postal codes for the primary contact.
Primary Contact Phone. Please fill in the previous information and new information updates to the primary contact phone number.
E-mail Address. (optional)

Today’s Date & Time:

Reference Number:

Taxpayer Identification Number (EIN or SSN):

Taxpayer’s Business Name or Individual’s Name:

PREVIOUS Information

NEW Information

1. Primary Contact Name:

7. NEW Primary Contact Name:

2. Primary Contact Mailing Street Address:

8. NEW Primary Contact Mailing Street Address:

3. City, State, and Zip Code:

9. NEW City, State, and Zip Code:

4. International Province, Country & Postal Code:

10. NEW International Province, Country & Postal Code:

5. Primary Contact Phone Number:

11. NEW Primary Contact Phone Number:
US ______ / ________ - ________

International 001-

area code

6. E-mail Address:

12. NEW E-mail Address:

Taxpayer Name (printed)

Taxpayer Title/Position

Taxpayer Name Signature

Date

country

city

number

IMPORTANT: All forms require a signature in order to be processed. All Fields must be completed or it may delay the processing of requested changes.

Fax completed & signed document to 866-568-2490
For questions regarding EFTPS or this Form please call:
EFTPS Customer Service

1-800-555-4477

(24 hours a day, 7 days a week)

For TDD (hearing impaired support)

1-800-733-4829

(8 a.m. to 8 p.m. Eastern Time)

en español

1-800-244-4829

(8 a.m. to 8 p.m. Eastern Time)

For Internal Use Only: Submitted by: ____________________________________