Common use of INSTRUCTIONS TO EMPLOYER Clause in Contracts

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: 0-000-000-0000 (Business), or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 0-000-000-0000 (Individuals – Wage Earners) THANK YOU FOR YOUR COOPERATION Catalog No. 21475H xxx.xxx.xxx Form 2159 (Rev. 1-2015) Form 2159(Rev. January 2015) Department of the Treasury — Internal Revenue Service Payroll Deduction Agreement (See Instructions on the back of this page.) TO: (Employer name and address) Regarding: (Taxpayer name and address) Contact Person’s Name Telephone (Include area code) Social security or employer identification number (Taxpayer) (Spouse, last four digits) EMPLOYER — See the instructions on the back of Part 2. The taxpayer identified above Your telephone number (Include area code) on the right named you as an employer. Please read and sign the following statement toagree to withhold amount(s) from the taxpayer’s (employee’s) wages or salary to apply to (Home) (Work or business) taxes owed. For assistance, call: 0-000-000-0000 (Business) or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 0-000-000-0000 (Individuals – Wage Earners) Or write: Campus (City, State, and ZIP Code) 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 OTHER (Specify.) Signed: Financial Institution(s) (Name and address) Title: Date: Kinds of taxes (Form numbers) Tax Periods Amount owed as of $ , plus all penalties and interest provided by law. I am paid every (Check one): WEEK TWO WEEKS MONTH OTHER (Specify.) I agree to have $ 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) Date FOR IRS USE ONLY: AGREEMENT LOCATOR NUMBER: Originator’s ID #: Originator Code: Check the appropriate boxes: Name: Title: RSI “1” no further review AI “0” Not a PPIA RSI “5” PPIA IMF 2 year review AI “1” Field Asset PPIA A NOTICE OF FEDERAL TAX LIEN (Check one box.) RSI “6” PPIA BMF 2 year review AI “2” All other PPIAs HAS ALREADY BEEN FILED Agreement Review Cycle: WILL BE FILED IMMEDIATELY Earliest CSED: WILL BE FILED WHEN TAX IS ASSESSED Check box if pre-assessed modules included MAY BE FILED IF THIS AGREEMENT DEFAULTS Agreement examined or approved by (Signature, title, function) Date Part 3 — Taxpayer’s Copy Catalog Xx. 00000X xxx.xxx.xxx Xxxx 2159 (Rev. 1-2015)

INSTRUCTIONS TO EMPLOYER. This payroll deduction agreement is subject to 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 all parts of the form, please return the parts of the form which were requested on the letter the employee received with the formit (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: 0-000-000-0000 (Business), or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 0-000-000-0000 (Individuals – Wage Earners) THANK YOU FOR YOUR COOPERATION Catalog No. 21475H xxx.xxx.xxx Form 2159 (Rev. 1-2015) Form 2159(Rev. January 20152007) Department of the Treasury — Internal Revenue Service Payroll Deduction Agreement (See Instructions on the back of this page.) TO: (Employer name and address) Regarding: (Taxpayer name and address) Contact Person’s Name Telephone (Include area code) Social security or employer identification number (Taxpayer) (Spouse, last four digits) EMPLOYER — EMPLOYER—See the instructions on the back of Part 2. The taxpayer identified above Your telephone number (Include area code) on the right named you as an employer. Please read and sign the following statement toagree to agree to withhold amount(s) from the taxpayer’s (employee’s) wages or salary to apply to (Home) (Work or business) taxes owed. For assistance, call: 0-000-000-0000 (Business) or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 0-000-000-0000 (Individuals – Wage Earners) Or write: Campus (City, State, and ZIP Code) 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.) Your telephone number (Include area code)(Home) (Work or business) For assistance, call: 0-000-000-0000 (Business) or1-800-829-8374 (Individual – Self-Employed/Business Owners), or1-800-829-0922 (Individuals – Wage Earners) Or write: Campus (City, State, and ZIP Code) WEEK TWO WEEKS MONTH OTHER (Specify.) Signed: Financial Institution(s) (Name and address) Signed: Title: Date: Kinds of taxes (Form numbers) Tax Periods Amount owed as of $ , plus all penalties and interest provided by law. I am paid every every: (Check one): WEEK TWO WEEKS MONTH OTHER (Specify.) I agree to have $ deducted from my wage or salary payments payment 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 authority to deduct this fee from your first payment(s) after 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) Date FOR IRS USE ONLY: AGREEMENT LOCATOR NUMBER: Originator’s ID #: Originator Code: Check the appropriate boxes: Name: Title: RSI “1” no further review AI “0” Not a PPIA RSI “5” PPIA IMF 2 year review AI “1” Field Asset PPIA A NOTICE OF FEDERAL TAX LIEN (Check one box.) RSI “6” PPIA BMF 2 year review AI “2” All other PPIAs HAS ALREADY BEEN FILED Agreement Review Cycle: WILL BE FILED IMMEDIATELY Earliest CSED: WILL BE FILED WHEN TAX IS ASSESSED Check box if pre-assessed modules included MAY BE FILED IF THIS AGREEMENT DEFAULTS Agreement examined or approved by (Signature, title, function) Date Part 3 — Taxpayer’s Copy Catalog Xx. 00000X xxx.xxx.xxx Xxxx 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: 0-000-000-0000 (Business), or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 01-000800-000829-0000 0922 (Individuals – Wage Earners) THANK YOU FOR YOUR COOPERATION Catalog No. 21475H xxx.xxx.xxx Form 2159 (Rev. 1-2015) Form 2159(Rev. January 2015) Department of the Treasury — Internal Revenue Service Payroll Deduction Agreement (See Instructions on the back of this page.) TO: (Employer name and address) Regarding: (Taxpayer name and address) Contact Person’s Name Telephone (Include area code) Social security or employer identification number (Taxpayer) (Spouse, last four digits) EMPLOYER — See the instructions on the back of Part 2. The taxpayer identified above Your telephone number (Include area code) on the right named you as an employer. Please read and sign the following statement toagree to agree to withhold amount(s) from the taxpayer’s (employee’s) wages or salary to apply to (Home) (Work or business) taxes owed. For assistance, call: 0-000-000-0000 (Business) or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 0-000-000-0000 (Individuals – Wage Earners) Or write: Campus (City, State, and ZIP Code) 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 OTHER (Specify.) Signed: Title: Date: Your telephone number (Include area code) (Home) (Work or business) For assistance, call: 0-000-000-0000 (Business) or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 1-800-829-0922 (Individuals – Wage Earners) Or write: Campus (City, State, and ZIP Code) Financial Institution(s) (Name and address) Title: Date: Kinds of taxes (Form numbers) Tax Periods Amount owed as of $ , plus all penalties and interest provided by law. I am paid every (Check one): WEEK TWO WEEKS MONTH OTHER (Specify.) I agree to have $ 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) Date FOR IRS USE ONLY: AGREEMENT LOCATOR NUMBER: Originator’s ID #: Originator Code: Check the appropriate boxes: Name: Title: RSI “1” no further review AI “0” Not a PPIA RSI “5” PPIA IMF 2 year review AI “1” Field Asset PPIA A NOTICE OF FEDERAL TAX LIEN (Check one box.) RSI “6” PPIA BMF 2 year review AI “2” All other PPIAs HAS ALREADY BEEN FILED Agreement Review Cycle: WILL BE FILED IMMEDIATELY Earliest CSED: WILL BE FILED WHEN TAX IS ASSESSED Check box if pre-assessed modules included MAY BE FILED IF THIS AGREEMENT DEFAULTS Agreement examined or approved by (Signature, title, function) Date Part 3 — Taxpayer’s Copy Catalog Xx. 00000X xxx.xxx.xxx Xxxx 2159 (Rev. 1-2015)Date

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: 0-000-000-0000 (Business), or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 01-000800-000829-0000 0922 (Individuals – Wage Earners) THANK YOU FOR YOUR COOPERATION Catalog No. 21475H xxx.xxx.xxx Form 2159 (Rev. 1-2015) Form 2159(Rev. January 2015July 2018) Department of the Treasury — Internal Revenue Service Payroll Deduction Agreement (See Instructions on the back of this page.) TO: (Employer name and address) Regarding: (Taxpayer name and address) Contact Person’s Name Telephone (Include area code) Social security or employer identification number (Taxpayer) (Spouse, last four digits) EMPLOYER — See the instructions on the back of Part 2. The taxpayer identified above Your telephone number (Include area code) on the right named you as an employer. Please read and sign the following statement toagree to agree to withhold amount(s) from the taxpayer’s (employee’s) wages or salary to apply to (Home) (Work or business) taxes owed. For assistance, call: 0-000-000-0000 (Business) or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 0-000-000-0000 (Individuals – Wage Earners) Or write: Campus (City, State, and ZIP Code) 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 OTHER (Specify.) Signed: Financial Institution(s) (Name and address) Title: Date: Debit Payments Self-Identifier If you are unable to make electronic payments through a debit instrument (debit payments) by entering into a direct debit installment agreement please check the box below: I am unable to make debit payments Note: Not checking this box indicates that you are able but choosing not to make debit payments. See Instructions to Taxpayer below for more details. For assistance, call: 0-000-000-0000 (Business) or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 1-800-829-0922 (Individuals – Wage Earners) Or write: Campus (City, State, and ZIP Code) Kinds of taxes (Form numbers) Tax Periods Amount owed as of $ , plus all penalties and interest provided by law. I am paid every (Check one): WEEK TWO WEEKS MONTH OTHER (Specify.) I agree to have $ 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 paymentpayment or accrue an additional liability, 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 $120 225 user fee, which we have authority to deduct from your first payment(s). You may be eligible for a reduced user fee of $4343 that may be waived or reimbursed if certain conditions are met. See Form 13844 for qualifications and instructions. • If you default on your installment agreement, you must pay a $50 89 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) Date FOR IRS USE ONLY: AGREEMENT LOCATOR NUMBER: Originator’s ID #: Originator Code: Check the appropriate boxes: Name: Title: RSI “1” no further review AI “0” Not a PPIA RSI “5” PPIA IMF 2 year review AI “1” Field Asset PPIA A NOTICE OF FEDERAL TAX LIEN (Check one box.) RSI “6” PPIA BMF 2 year review AI “2” All other PPIAs HAS ALREADY BEEN FILED Agreement Review Cycle: WILL BE FILED IMMEDIATELY Earliest CSED: WILL BE FILED WHEN TAX IS ASSESSED Check box if pre-assessed modules included MAY BE FILED IF THIS AGREEMENT DEFAULTS Agreement examined or approved by (Signature, title, function) Date Part 3 — Taxpayer’s Copy Catalog Xx. 00000X xxx.xxx.xxx Xxxx 2159 (Rev. 1-2015)Date

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 duestop. 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: 0-000-000-0000 (Business), or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 0-000-000-0000 (Individuals – Wage Earners) THANK YOU FOR YOUR COOPERATION Catalog No. Number 21475H xxx.xxx.xxx Form 2159 (Rev. 15-20152020) Form 2159(Rev. January 20152159 (May 2020) Department of the Treasury — Internal Revenue Service Payroll Deduction Agreement (See Instructions on the back of this page.) TO: (Employer name and address) Regarding: (Taxpayer name and address) Contact Personperson’s Name name Telephone (Include area code) Social security or employer identification number (Taxpayer) (Spouse, last four digits) EMPLOYER — See the instructions on the back of Part 2. The taxpayer identified above Your telephone number (Include area code) on aboveon the right named you as an employer. Please read and sign the following statement toagree to agree to withhold amount(s) from the taxpayer’s (employee’s) wages or salary to apply to (Home) (Work or business) 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 OTHER (Specify) Date by which payments will be sent beginning on . Signed: Title: Date: Debit Payments Self-Identifier If you are unable to make electronic payments through a debit instrument (debit payments) by entering into a direct debit installment agreement, please check the box below: I am unable to make debit payments Note: Not checking this box indicates that you are able but choosing not to make debit payments. See Instructions to Taxpayer below for more details. For assistance, call: 0-000-000-0000 (Business) or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 0-000-000-0000 (Individuals – Wage Earners) Or write: Campus (City, State, and ZIP Code) 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 OTHER (Specify.) Signed: Financial Institution(s) (Name and address) Title: Date: Kinds of taxes (Form numbers) Tax Periods periods Amount owed as of $ , plus all penalties and interest provided by law. I am paid every (Check one): WEEK TWO WEEKS MONTH OTHER (Specify.) I agree to have $ deducted from my wage or salary payments beginning and paid by the employer to the IRS until the total liability is paid in full. l I also agree and authorize this deduction to be increased or decreased as follows: Date of increase (or decrease) Amount of Increase 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 paymentpayment or accrue an additional liability, 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 $120 225 user fee, which we have authority to deduct from your first payment(spayment (s). You may be eligible for a reduced user fee of $4343 that may be waived or reimbursed if certain conditions are met. See Form 13844 for qualifications and instructions. • If you default on your installment agreement and we terminate the agreement, you must pay a $50 89 reinstatement fee if we reinstate the agreement. You may be eligible for a reduced user fee of $43 that may be waived or reimbursed if certain conditions are met. See Form 13844 for qualifications and instructions. We have the authority to deduct this fee from your first payment(s) after the agreement is reinstated. If reinstated, you agree to the terms of this agreement as stated herein. Additional terms (To be completed by IRS) • We will apply all payments on this agreement in the best interests of the United States. Generally 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 • By signing and submitting this form, you authorize the IRS to contact third parties and to disclose your tax information to third parties in order to process and maintain administer this agreementagreement over its duration. Your signature Title (If Corporate Officer or Partner) Date Spouse’s signature (If a joint liability) Date FOR IRS USE ONLY: AGREEMENT LOCATOR NUMBER: Originator’s ID #: Originator Code: Check the appropriate boxes: Name: Title: RSI “1” no further review AI “0” Not a PPIA RSI “5” PPIA IMF 2 2-year review AI “1” Field Asset PPIA A NOTICE OF FEDERAL TAX LIEN (Check one box.) RSI “6” PPIA BMF 2 2-year review AI “2” All other PPIAs HAS ALREADY BEEN FILED Agreement Review Cycle: WILL BE FILED IMMEDIATELY Earliest CSED: WILL BE FILED WHEN TAX IS ASSESSED Check box if pre-assessed modules included MAY BE FILED IF THIS AGREEMENT DEFAULTS Agreement examined or approved by (Signature, title, function) Date Part 3 — Taxpayer’s Copy Catalog Xx. 00000X Number 21475H xxx.xxx.xxx Xxxx Form 2159 (Rev. 15-20152020)

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: 0-000-000-0000 (Business), or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 0-000-000-0000 (Individuals – Wage Earners) THANK YOU FOR YOUR COOPERATION Catalog No. 21475H xxx.xxx.xxx Form 2159 (Rev. 17-20152018) Form 2159(Rev. January 20152159 (July 2018) Department of the Treasury — Internal Revenue Service Payroll Deduction Agreement (See Instructions on the back of this page.) TO: (Employer name and address) Regarding: (Taxpayer name and address) Contact Person’s Name Telephone (Include area code) Social security or employer identification number (Taxpayer) (Spouse, last four digits) EMPLOYER — See the instructions on the back of Part 2. The taxpayer identified above Your telephone number (Include area code) on the right named you as an employer. Please read and sign the following statement toagree to agree to withhold amount(s) from the taxpayer’s (employee’s) wages or salary to apply to (Home) (Work or business) 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 OTHER (Specify.) Signed: Title: Date: Debit Payments Self-Identifier If you are unable to make electronic payments through a debit instrument (debit payments) by entering into a direct debit installment agreement please check the box below: I am unable to make debit payments Note: Not checking this box indicates that you are able but choosing not to make debit payments. See Instructions to Taxpayer below for more details. For assistance, call: 0-000-000-0000 (Business) or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 0-000-000-0000 (Individuals – Wage Earners) Or write: Campus (City, State, and ZIP Code) 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 OTHER (Specify.) Signed: Financial Institution(s) (Name and address) Title: Date: Kinds of taxes (Form numbers) Tax Periods Amount owed as of $ , plus all penalties and interest provided by law. I am paid every (Check one): WEEK TWO WEEKS MONTH OTHER (Specify.) I agree to have $ 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 paymentpayment or accrue an additional liability, 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 $120 225 user fee, which we have authority to deduct from your first payment(s). You may be eligible for a reduced user fee of $4343 that may be waived or reimbursed if certain conditions are met. See Form 13844 for qualifications and instructions. • If you default on your installment agreement, you must pay a $50 89 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) Date FOR IRS USE ONLY: AGREEMENT LOCATOR NUMBER: Originator’s ID #: Originator Code: Check the appropriate boxes: Name: Title: RSI “1” no further review AI “0” Not a PPIA RSI “5” PPIA IMF 2 year review AI “1” Field Asset PPIA A NOTICE OF FEDERAL TAX LIEN (Check one box.) RSI “6” PPIA BMF 2 year review AI “2” All other PPIAs HAS ALREADY BEEN FILED Agreement Review Cycle: WILL BE FILED IMMEDIATELY Earliest CSED: WILL BE FILED WHEN TAX IS ASSESSED Check box if pre-assessed modules included MAY BE FILED IF THIS AGREEMENT DEFAULTS Agreement examined or approved by (Signature, title, function) Date Part 3 — Taxpayer’s Copy Catalog XxNo. 00000X 21475H xxx.xxx.xxx Xxxx Form 2159 (Rev. 17-20152018)

INSTRUCTIONS TO EMPLOYER. This payroll deduction agreement is subject to 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 '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 formit (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 '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 n'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 '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: 0-000-000-0000 (Business), or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 01-000800-000829-0000 0922 (Individuals – Wage Earners) THANK YOU FOR YOUR COOPERATION Catalog No. 21475H xxx.xxx.xxx Form 2159 (Rev. 1-2015) Form 2159(Rev. January 2015April 2003) Department of the Treasury — Internal Revenue Service Payroll Deduction Agreement (See Instructions on the back of this page.) TO: (Employer name and address) Regarding: (Taxpayer name and address) Contact Person’s 's Name Telephone (Include area code) Social security or employer identification number (Taxpayer) (Spouse, last four digits) EMPLOYER — EMPLOYER—See the instructions on the back of Part 2. The taxpayer identified above Your telephone number (Include area code) on the right named you as an employer. Please read and sign the following statement toagree to agree to withhold amount(s) from the taxpayer’s 's (employee’s's) wages or salary to apply to (Home) (Work or business) taxes owed. For assistance, call: 0-000-000-0000 (Business) or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 0-000-000-0000 (Individuals – Wage Earners) Or write: Campus (City, State, and ZIP Code) 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 OTHER (Specify.) Signed: Title: Date: Your telephone number (Include area code) (Home) (Work or business) For assistance, call: 0-000-000-0000 (Business) or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 1-800-829-0922 (Individuals – Wage Earners) Or write: Campus (City, State, and ZIP Code) Financial Institution(s) (Name and address) Title: Date: Kinds of taxes (Form numbers) Tax Periods Amount owed as of $ , plus all penalties and interest provided by law. I am paid every every: (Check one): WEEK TWO WEEKS MONTH OTHER (Specify.) I agree to have $ deducted from my wage or salary payments payment 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) Date FOR IRS USE ONLY: AGREEMENT LOCATOR NUMBER: Originator’s ID #: Originator Code: Check the appropriate boxes: Name: Title: RSI “1” no further review AI “0” Not a PPIA RSI “5” PPIA IMF 2 year review AI “1” Field Asset PPIA A NOTICE OF FEDERAL TAX LIEN (Check one box.) RSI “6” PPIA BMF 2 year review AI “2” All other PPIAs HAS ALREADY BEEN FILED Agreement Review Cycle: WILL BE FILED IMMEDIATELY Earliest CSED: WILL BE FILED WHEN TAX IS ASSESSED Check box if pre-assessed modules included MAY BE FILED IF THIS AGREEMENT DEFAULTS Agreement examined or approved by (Signature, title, function) Date Part 3 — Taxpayer’s Copy Catalog Xx. 00000X xxx.xxx.xxx Xxxx 2159 (Rev. 1-2015)make

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: 0-000-000-0000 (Business), or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 01-000800-000829-0000 0922 (Individuals – Wage Earners) THANK YOU FOR YOUR COOPERATION Catalog No. 21475H xxx.xxx.xxx Form 2159 (Rev. 1-2015) Form 2159(Rev. January 2015November 2016) Department of the Treasury — Internal Revenue Service Payroll Deduction Agreement (See Instructions on the back of this page.) TO: (Employer name and address) Regarding: (Taxpayer name and address) Contact Person’s Name Telephone (Include area code) Social security or employer identification number (Taxpayer) (Spouse, last four digits) EMPLOYER — See the instructions on the back of Part 2. The taxpayer identified above Your telephone number (Include area code) on the right named you as an employer. Please read and sign the following statement toagree to agree to withhold amount(s) from the taxpayer’s (employee’s) wages or salary to apply to (Home) (Work or business) taxes owed. For assistance, call: 0-000-000-0000 (Business) or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 0-000-000-0000 (Individuals – Wage Earners) Or write: Campus (City, State, and ZIP Code) 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 OTHER (Specify.) Signed: Title: Date: Your telephone number (Include area code) (Home) (Work or business) For assistance, call: 0-000-000-0000 (Business) or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 1-800-829-0922 (Individuals – Wage Earners) Or write: Campus (City, State, and ZIP Code) Financial Institution(s) (Name and address) Title: Date: Kinds of taxes (Form numbers) Tax Periods Amount owed as of $ , plus all penalties and interest provided by law. I am paid every (Check one): WEEK TWO WEEKS MONTH OTHER (Specify.) I agree to have $ 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 paymentpayment or accrue an additional liability, 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 $120 225 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 89 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) Date FOR IRS USE ONLY: AGREEMENT LOCATOR NUMBER: Originator’s ID #: Originator Code: Check the appropriate boxes: Name: Title: RSI “1” no further review AI “0” Not a PPIA RSI “5” PPIA IMF 2 year review AI “1” Field Asset PPIA A NOTICE OF FEDERAL TAX LIEN (Check one box.) RSI “6” PPIA BMF 2 year review AI “2” All other PPIAs HAS ALREADY BEEN FILED Agreement Review Cycle: WILL BE FILED IMMEDIATELY Earliest CSED: WILL BE FILED WHEN TAX IS ASSESSED Check box if pre-assessed modules included MAY BE FILED IF THIS AGREEMENT DEFAULTS Agreement examined or approved by (Signature, title, function) Date Part 3 — Taxpayer’s Copy Catalog Xx. 00000X xxx.xxx.xxx Xxxx 2159 (Rev. 1-2015)Date

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 duestop. 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: 0-000-000-0000 (Business), or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 01-000800-000829-0000 0922 (Individuals – Wage Earners) THANK YOU FOR YOUR COOPERATION Catalog No. 21475H xxx.xxx.xxx Form 2159 (Rev. 1-2015) Form 2159(Rev. January 2015May 2020) Department of the Treasury — Internal Revenue Service Payroll Deduction Agreement (See Instructions on the back of this page.) TO: (Employer name and address) Regarding: (Taxpayer name and address) Contact Personperson’s Name name Telephone (Include area code) Social security or employer identification number (Taxpayer) (Spouse, last four digits) EMPLOYER — See the instructions on the back of Part 2. The taxpayer identified above Your telephone number (Include area code) on the right named you as an employer. Please read and sign the following statement toagree to agree to withhold amount(s) from the taxpayer’s (employee’s) wages or salary to apply to (Home) (Work or business) taxes owed. For assistance, call: 0-000-000-0000 (Business) or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 0-000-000-0000 (Individuals – Wage Earners) Or write: Campus (City, State, and ZIP Code) 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 OTHER (Specify.) Date by which payments will be sent beginning on . Signed: Financial Institution(s) (Name and address) Title: Date: Debit Payments Self-Identifier If you are unable to make electronic payments through a debit instrument (debit payments) by entering into a direct debit installment agreement, please check the box below: I am unable to make debit payments Note: Not checking this box indicates that you are able but choosing not to make debit payments. See Instructions to Taxpayer below for more details. For assistance, call: 0-000-000-0000 (Business) or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 1-800-829-0922 (Individuals – Wage Earners) Or write: Campus (City, State, and ZIP Code) Kinds of taxes (Form numbers) Tax Periods periods Amount owed as of $ , plus all penalties and interest provided by law. I am paid every (Check one): WEEK TWO WEEKS MONTH OTHER (Specify.) I agree to have $ deducted from my wage or salary payments beginning and paid by the employer to the IRS until the total liability is paid in full. l I also agree and authorize this deduction to be increased or decreased as follows: Date of increase (or decrease) Amount of Increase 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 paymentpayment or accrue an additional liability, 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 $120 225 user fee, which we have authority to deduct from your first payment(spayment (s). You may be eligible for a reduced user fee of $4343 that may be waived or reimbursed if certain conditions are met. See Form 13844 for qualifications and instructions. • If you default on your installment agreement and we terminate the agreement, you must pay a $50 89 reinstatement fee if we reinstate the agreement. You may be eligible for a reduced user fee of $43 that may be waived or reimbursed if certain conditions are met. See Form 13844 for qualifications and instructions. We have the authority to deduct this fee from your first payment(s) after the agreement is reinstated. If reinstated, you agree to the terms of this agreement as stated herein. Additional terms (To be completed by IRS) • We will apply all payments on this agreement in the best interests of the United States. Generally 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 • By signing and submitting this form, you authorize the IRS to contact third parties and to disclose your tax information to third parties in order to process and maintain administer this agreementagreement over its duration. Your signature Title (If Corporate Officer or Partner) Date Spouse’s signature (If a joint liability) Date FOR IRS USE ONLY: AGREEMENT LOCATOR NUMBER: Originator’s ID #: Originator Code: Check the appropriate boxes: Name: Title: RSI “1” no further review AI “0” Not a PPIA RSI “5” PPIA IMF 2 year review AI “1” Field Asset PPIA A NOTICE OF FEDERAL TAX LIEN (Check one box.) RSI “6” PPIA BMF 2 year review AI “2” All other PPIAs HAS ALREADY BEEN FILED Agreement Review Cycle: WILL BE FILED IMMEDIATELY Earliest CSED: WILL BE FILED WHEN TAX IS ASSESSED Check box if pre-assessed modules included MAY BE FILED IF THIS AGREEMENT DEFAULTS Agreement examined or approved by (Signature, title, function) Date Part 3 — Taxpayer’s Copy Catalog Xx. 00000X xxx.xxx.xxx Xxxx 2159 (Rev. 1-2015)Date