Department of the Treasury – Internal Revenue Service Form 13287 

(December 2009) Bank Payment Problem Identification 

Section I. 

Part 1: Taxpayer Information (For completion by bank) 

Information Supplied by Bank 

1. Taxpayer Identification Number (TIN) 

(DO NOT enter the EIN of the taxpayer's bank.) 

2. Multiple TINs 

Yes 

(See attached list) 

3. Form(s) Payment Intended For (if known) 4. Tax Period(s) Payment Intended For 

(if known) 

Part 2: Bank Information (For completion by bank) 

5. Name of Bank (Enter complete legal name of responsible bank) 6. Federal Employer Identification Number 

(FEIN) of Bank 

7. Bank Branch Street Address 8. Branch Number of Bank Where Problem 

Occurred 

9. City, State, ZIP Code 10. American Banking Association (ABA) Number 

11. Bank Contact Name and Title (Please print) 12. Telephone Number 

13. FAX Number 

14. Number of Payments Delayed 15. Payment / Combined Payments Amount 

$ 

17. Date T/P Requested

Payment (explain in item 26) 

18. Date Payment 

Transmitted 

19. Number of Days

Payment Late 

16. Method of Payment (“x” proper box) 

ACH debit ACH credit Coupon Fed wire 

20. Date IRS was 

Contacted 

21. Mode of Contact (“x” proper box) 

Phone FAX Letter 

22. Problem Involved Multiple Payments 

Yes (See attached list.) No 

23. Deposit Made More than 48 Hours After

Problem Discovered 

No Yes (Explain in Item 25.) 

24. IRS Contacted within 48 Hours of Problem 

Discovery 

Yes No (Explain in Item 25.)

Signature

Authorization of 

Bank Official 

25. Explanation (Items 23 and 24) 

26. Brief explanation why payment could not be processed as taxpayer requested 

By signing below, I understand that the financial institution listed above will accept responsibility for the payment(s) delay. 

27. Name (Please print) 28. Title 

29. Signature 30. Date 

Section II. INFORMATION SUPPLIED BY INTERNAL REVENUE SERVICE 

Part 3: IRS Information (For completion by IRS) 

31. History 32. Resolution 

33. Name of Taxpayer 34. Taxpayer 

Correspondence Date 

35. Date Bank's Completed Form 

13287 received at IRS 

36. Method of Taxpayer Contact 

(“x” proper box) 

Phone FAX Letter

37. TC 971 

Action Code 30 ___ 

38. Payment Date 39. Intended Payment Date 40. Additional Action(s) for Adjustment(s) 

to Account (TC 181, ADX 48/24/34) 

41. IRS Contact Name (Please print) 42. IRS Contact Employee 

Number 

43. IRS Contact Phone Number 

44. IDRS Input Date (mm/dd/yyyy) 45. Master File Projected 23C 

Posting Date 

46. Date Information FAXd to Federal 

Reserve Board (FRB) 

Catalog No. 34294M www.irs.gov Form 13287 (Rev. 12-2009) 

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Instructions for Completing Form 13287, Bank Problem Identification Worksheet 

GENERAL— When a bank delays forwarding a taxpayer's “timely received with proper instructions” Federal Tax Deposit 

(FTD) to the U.S. Treasury, the taxpayer may be relieved of the portion of the FTD penalty pertaining to that payment, if the 

bank accepts responsibility for the delay. For each delayed FTD payment or issue, FAX a separate Form 13287 and 

Instructions to the responsible bank for completion and a bank official's signature. The signed form then becomes the 

authorization for the Federal Reserve Board (FRB) to charge the bank for the loss of funds to the U.S. Treasury. 

SECTION I. INFORMATION SUPPLIED BY BANK 

Part 1: Taxpayer Information

(Items 1 thru 4 for completion by bank) 

Item 1: Taxpayer Identification Number (TIN) — 

Enter the Employer Identification Number (EIN) or Social 

Security Number (SSN) of the taxpayer. (DO NOT enter the

EIN of the taxpayer's bank.) 

Item 2: Multiple TIN(s) — 

If multiple TINs (clients) are involved in this issue, please 

indicate this and attach a list to this document.  The list should 

include the clients’ TIN(s), the deposit date(s), the deposit 

amount(s), and the form(s) and tax period(s) where the deposit 

was intended. 

Item 3: Form(s) — 

Enter the Form number of the account where the deposit was 

intended (if known). If the payment was submitted for an 

incorrect form number, please notate that form in Item # 26. 

Item 4: Tax Period(s) — 

Enter the Tax Period of the account where the deposit was 

intended (if known). If the payment was submitted for an 

incorrect tax period, please notate that tax period in Item # 26. 

Part 2: Bank Information 

(Items 5 thru 30 for completion by bank) 

Item 10: American Banking Association (ABA) Number — 

Enter the ABA number of the responsible bank for assessment 

of the cost of funds (loss of interest). 

Item 11: Bank Contact Name and Title — 

Enter the name and title of the bank contact person who can 

discuss this issue. 

Item 14: Number of Payments Delayed —

If only one payment was delayed, enter “1” in this block. If 

more than one, enter the total and attach a separate 

spreadsheet which shows the breakdown by TIN of the 

individual payment amounts (see Item # 2). 

Item 15: Payment / Combined Payments Amount —

Enter the single payment amount or, if multiple payments are 

involved, enter the total of all delayed payments. 

Item 17: Date T/P Requested Payment (mm/dd/yyyy) —

Enter the date the taxpayer requested the payment to post to 

their IRS account. (This usually is the due date.) 

Item 19: Number of Days Payment Late —

Enter the number of days elapsed between the date the 

payment should have been posted to the taxpayer's IRS 

account and the date it actually posted (settlement date and 

the intended settlement date). 

Item 20: Date IRS was contacted (mmddyyyy) —

Enter the date the IRS was first contacted about the issue. 

SECTION II. INFORMATION SUPPLIED BY IRS 

Part 3: IRS Information 

(Items 31 thru 46 for completion by IRS) 

Item 31: History —

Enter a brief history of any actions, contacts, etc. 

Item 32: Resolution — 

Enter a brief history of actions taken to resolve this issue. 

Item 33: Name of Taxpayer —

If the case only involves one TIN, list the name of the 

taxpayer(s) or business. 

Item 34: Taxpayer correspondence date (mmddyyyy) — 

Enter the date the taxpayer first contacted IRS about this 

issue. 

Item 36: Method of Taxpayer Contact (mm/dd/yyyy) — 

Enter the mode the taxpayer used to contact the IRS about 

this issue. 

Item 37: TC 971 — 

For TC971 input, enter “1 – 9” for action codes 301-309. If 

TC971 cannot be input, prepare a Form 8646, Checklist to 

Identify Delays in Processing Federal Tax Deposits (FTDs). 

Item 38: Payment Date (mm/dd/yyyy ) — 

Enter the date the payment was posted to the taxpayer's 

account. 

Item 39: Intended Payment Date (mm/dd/yyyy ) — 

Enter the date the payment should have posted to the 

taxpayer's account. 

Item 40: Additional Action(s) for Adjustment(s) to

Account (TC 181, ADX 48/24/34) — 

Enter any other actions taken in addition to the TC 971 (or in 

place of). 

Item 41: IRS contact name — 

Enter the name of the person who worked the case. 

Catalog No. 34294M www.irs.gov Form 13287 (Rev. 12-2009)