rejected. If you don't have a prior year Adjusted Gross Income you can obtain an 

Amount you are paying (see instructions)

Checking         Savings         N/A (no direct debit)

Form 4868Application for Automatic Extension of TimeOMB NO. 1545-0074

Department of the Treasuryto File U.S. Individual Income Tax Return2013

Internal Revenue Service (99)For calendar year 2013, or other tax year beginning,2013 ending, 20.

Part IIdentificationPart IIIndividual Income Tax

1Your name(s) (see instructions)4Estimate of total tax liability for 2013. . . . . . . . . . $

5Total 2013 payments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Address (see instructions)6     Balance due.  Subtract line 5 from line 4

(see instructions). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

City, town or post officeState       ZIP Code7. . . . . G

8Check here if you are "out of the country" and a U.S.

Foreign country nameProvince    Postal Code           citizen or resident (see instructions). . . . . . . . . . . . . . . . . G

9Check here if you file Form 1040NR or 1040NR-EZ and

2Your social security number3Spouse's social security numberdid not receive wages as an employee subject to U.S.

income tax withholding. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G

For Privacy Act and Paperwork Reduction Act Notice, see page 4.Cat. No. 13141WForm 4868 (2013)

Information for Paper Filing of Extension           Required Information for Electronic Filing of Extension

Paying Tax Due by Check. . . . . . . . . . . . . . 

. . . . . . . . . . . . . . . . in the instructions.

Disclosure StatementI agree

I consent to allow my Intermediate Service Provider, transmitter, or Electronic Return Originator (ERO) to 

send this form to the IRS and to receive the following information from the IRS: (a) Acknowledgement of 

receipt or reason for rejection of transmission , and (b) if delayed, reason for any delay in processing the 

form.

Paying Tax Due by Check  

Print Form 4868 and attach check for balance due. Mail to the address in the instructions

Electronic Withdrawal of Tax Due

To use direct debit, enter the required information below and agree to the disclosure statement.

GRouting number. . . . . . . . . . . 

GAccount number. . . . . . . . . . . 

GType:. . . . . . . . . . . . . . . . . . . . . . 

Date to make withdrawal. . . . . . . . . . . . 

GDay time phone number. . . . . . . . . . . . . . . . . . . . . 

IMPORTANT: Identifying Information From Last Year (2012 taxes)

The IRS uses this information to verify your identity. They will match this information against what 

they have in their records, so don't guess.  If the information does not match, your return will be 

Electronic Filing PIN from the IRS web site. Go to

http://www.irs.gov/Individuals/Electronic-Filing-PIN-Request or call 1-866-704-7388. 

Enter the Electronic Filing PIN  in the space indicated "Electronic Filing PIN".

Note:If you are married filing joint, and you filed together in 2012, enter the same 

amount in the taxpayer and spouse columns for adjusted gross income.

TaxpayerSpouse

(1) Prior Year Adjusted Gross Income:. . . . . . . . 

OR

(2) Electronic Filing PIN:. . . . . . . . . . . . . . . . . . . . . . . 

- Print Form 4868 and

attach check for balance due. Mail to the address Re-enter e-mail address (must match)

       E-Mail address (for confirmation e-mail

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(Your PIN(s) cannot be 12345 or 00000). . . . . . 

Date of Birth (mm/dd/yyyy). . . . . . . . . . . . . . . . . . . . 

Today's Date (mm/dd/yyyy). . . . . . . . . . . . . . . . . . . . 

Electronic withdrawal disclosure statementI agree

I authorize the U.S. Treasury and its designated Financial Agent to intitiate an ACH Electronic Funds 

Withdrawal (Direct Debit) entry to the financial institution account indicated for payment of my federal taxes 

owed on this return and the financial institution to debit the entry to this account.  This authorization is to 

remain in full force and effect until I notify the U.S. Treasure Financial Agent to terminate the authorization. 

To revoke a payment, I must contact the U.S. Treasury Financial Agent at 1-888-353-4537 no later than 2 

business days prior to the payment (settlement) date.  I also authorize the financial institutions involved in the

processing of the electronic payment of taxes to receive confidential information necessary to answer 

inquiries and resolve issues related to the payment.

Signature information

TaxpayerSpouse

Select any 5-digit PIN

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