$1$

Enter your employer identification

number $($EIN$).$

$2$

Enter the amount of your payment.

Make your check or money order payable to $$United States Treasury$$

Dollars

Cents

$3$

Tax Period

$1$st

Quarter

$3$rd

Quarter

$2$nd

Quarter

$4$th

Quarter

$4$

Enter your business name $($individual name if sole proprietor$).$

Enter your address.

Enter your city, state, and ZIP code or your city, foreign country name, foreign province$/$county$,$ and

foreign postal code.