EFTA01220917.pdf

Farm 9465 (Rev. December 2013) Installment Agreement Request ► Information about Form 9465 and its separate instructions is at wwwits.govilom79465. OMB No. 154S-0074 Department of the Treasury ► If you are filing this form with your tax return, attach it to the front of the return. Internal Revenue Senna/ ► See separate instructions. Tip: If you owe $50,000 or less, you may be able to establish an installment agreement online, even if you have not yet received a bill for your taxes. Go to IRS.gov to apply to pay online. Caution: Do not file this form if you are currently making payments on an installment agreement or can pay your balance in full within 120 days. Instead, call 1-800-829-1040. Do not file if your business is still operating and owes employment or unemployment taxes. Instead, call the telephone number on your most recent notice. If you are in bankruptcy or we have accepted your offer-in-compromise, see Bankruptcy or offer-in-compromise, in the instructions. Part I This request is for Forrn(s) (kr example. Form 1040 or Form 941)► and for tax year(s) (fix xample, 2012 and 2013)► ia Your first name and elitial Last name Your social security number If a joint return. spouse's first name and initial Last name Spouse's social security number Current address (number and street). If you have a box and no home &silvery. enter your box number. Apt. number City. town a post office. state. and ZIP code. If a foreign address. also complete the spaces below (see nstructions) Foreign country name Foreign province/state/coulty Foreign postal code 1b If this address is new since you filed your last tax return, check here D 2 Name of your business (must be no longer operating) Employer identification number (Elhg 3 4 Your home phone number Best time for us to call Your work phone number Best time for us to call 5 Name of your bark or other financial institution: Your employers name: Address Address City, state, and ZIP code City, state, and ZIP code 7 Enter the total amount you owe as shown on your tax retum(s) (or notice(s)) 7 8 Enter the amount of any payment you are making with your tax retum(s) (or notice(s)). See instructions 8 9 Subtract line 8 from line 7 and enter the result 9 10 Enter the amount you can pay each month. Make your payments as large as possible to limit interest and penalty charges. The charges will continue until you pay in full. If no payment amount is listed on line 10, a payment will be determined for you by dividing the balance due by 72 months . . 10 11 Divide the amount on line 9 by 72 and enter the result 11 • If the amount on line 10 is less than the amount on line 11 and you are unable to increase your payment to the amount on line 11, complete and attach Form 433-F, Collection Information Statement. • If the amount on line 10 is equal to or greater than the amount on line 11 but the amount you owe is greater than $25,000 but not more than $50,000, you must complete either line 13 or 14, if you do not wish to complete Form 433-F. • If the amount on line 9 is greater than $50,000, complete and attach Form 433-F, Collection Information Statement. 12 Enter the date you want to make your payment each month. Do not enter a date later than the 28th ► 13 If you want to make your payments by direct debit from your checking account, see the instructions and fill in lines 13a and 13b. This is the most convenient way to make your payments and it will ensure that they are made on time. ► a Routing number ► b Account number I authorize the U.S. Treasury and its designated Financial Agent to initiate a monthly ACH debit (electronic withdrawal) entry to the financial institution account indicated for payments of my Federal taxes owed, 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. Treasury Financial Agent to terminate the authorization. To revoke payment, I must contact the U.S. Treasury Financial Agent at 14004329-1040 no later than 14 business days prior to the payment (settlement) date. I also authorize the financial institutions involved in the processing of the electronic payments of taxes to receive confidential information necessary to answer inquiries and resolve issues related to the payments. 14 If you want to make your payments by payroll deduction, check this box and attach a completed Form 2159, Payroll Deduction Agreement Your signature I Date Spouse's signature. If a joint retum. both must sign. Date For Privacy Act and Paperwork Reduction Act Notice. see instructions. Form 9465 (Rev. 12-2013) EFTA01220917 Form 9465 (Rev. 12-2013) Page 2 Additional information. Complete this part only if you have defaulted on an installment agreement within the past 12 months and the amount you owe is greater than $25,000 but not more $50,000 and the amount on line 10 is equal to or greater than the amount on line 11. If you owe more than $50,000, complete and attach Form 433-F, Collection Information Statement. 15 In which county is your primary residence? 16a Marital status: ❑ Single. Skip question 16b and go to question 17. ❑ Married. Go to question 16b. b Do you share household expenses with your spouse? ❑ Yes. ❑ No. 17 How many dependents will you be able to claim on this year's tax return? 17 I 18 How many people in your household are 65 or older? 18 I 19 How often are you paid? ❑ Once a week. ❑ Once every two weeks. ❑ Once a month. ❑ Twice a month. 20 What is your net income per pay period (take home pay)? 20 Is 21 How often is your spouse paid? ❑ Once a week. ❑ Once every two weeks. ❑ Once a month. ❑ Twice a month. 22 What is your spouse's net income per pay period (take home pay)? 122 Is 23 How many vehicles do you own? I 23 I 24 How many car payments do you have each month? 124 I 25a Do you have health insurance? ❑ Yes. Go to question 25b. ❑ No. Skip question 25b and go to question 26a. b Are your premiums deducted from your paycheck? ❑ Yes. Skip question 25c and go to question 26a. ❑ No. Go to question 25c. c How much are your monthly premiums? Inc Is 26a Do you make court-ordered payments? ❑ Yes. Go to question 26b. ❑ No. Go to question 27. b Are your court-ordered payments deducted from your paycheck? ❑ Yes. Go to question 27. ❑ No. Go to question 26c. c How much are your court-ordered payments each month? I26c Is 27 Not including any court-ordered payments for child and dependent support, how much do you pay for child or dependent care each month/ I 27 IS Form 9465 (Rev. 12-2013) EFTA01220918