Payment Agreement Request

If you have an outstanding income tax balance and would like to request a payment agreement, you must fill out this form completely. Failure to provide all information may delay processing and/or result in your request for a payment agreement being denied.

Taxpayer Social Security # *

First Name *

Last Name *

Spouse Social Security # (if joint)

Spouse First Name (if joint)

Spouse Last Name (if joint)

Street Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Taxpayer Employer Name *

Spouse Employer Name (if joint)

Total Estimated Outstanding Balance *

Monthly Payment Requested *

*Note: Our minimum montly payment amount is generally the greater of either $50 per month or your balance divided over a 12 month term. If your situation prevents you from commiting to that minimum payment, enter the amount you are able to commit to and check the box below stating that you are unable to commit to the minimum amount required. The income tax department will contact you to discuss this issue further.

I am unable to commit to the minimum payment requirement listed above. Please contact me to discuss my situation further.

Would you like to have your payment automatically deducted from a bank account or charged to a credit card on file each month? *

Yes

No

Automatic payments are processed on the 15th and the 30th of each month. Please pick which one of these dates you'd prefer your payment to be processed. (If the date falls on a non-business day, it will be processed on the next business day.) *

15th or next business day

30th or next business day

What date would you like your first payment processed? (Please keep in mind, payments are processed on the 15th and the 30th). * +

Would you like to make a one time down payment on your balance today using the payment method selected below? *

Yes

No

Down Payment Amount (will be processed on the next business day) *

Choose payment method (this information will be used to process the payment options selected above). *

Credit / Debit Card (3% processing fee, min of $1.50 applies)

Electronic Check (No processing fee)

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

CVV *

9 Digit Routing Number *

Account Number *

*Please verify you have entered the correct payment information!

Incorrect payment information may delay processing.

Returned e-checks are subject to a $30.00 fee.

Acknowledgement and Agreement

Under the penalty of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. If prepared by a person other than the taxpayer, the preparer's declaration is based on all information of which preparer has any knowledge. Also, by signing below, you authorize the Income Tax Department to contact you via e-email regarding this payment agreement request.

Signature of taxpayer requesting payment agreement *

clear

Signing Taxpayer Name *

Date * +

Once you have submitted this form, you will receive a reference number and cannot go back to this page later. You will not receive an email confirmation.