Application for Extension of Time for Payment of
OMB No. 1545-2131
(Rev. December 2011)
Tax Due to Undue Hardship
Department of the Treasury
Internal Revenue Service
Before you begin: Use the chart on page 3 to see if you should file this form.
Name(s) shown on return
Number, street, and apt., room, or suite no. If you have a P.O. box, see instructions.
City, town, or post office, state, and ZIP code. If you have a foreign address, see instructions.
Request for Extension
I request an extension from
, to pay tax of $
This request is for (check only one box):
The tax shown or required to be shown on Form
An amount determined as a deficiency on Form
This request is for calendar year 20
, or fiscal year ending
Reason for Extension
Undue hardship. Enter below a detailed explanation of the undue hardship that will result if your application is denied. (If more space
is required, please attach a separate sheet.) To establish undue hardship, you must show that you would sustain a substantial
financial loss if forced to pay a tax or deficiency on the due date. For a complete definition of “undue hardship,” see the instructions
on page 3 under Who Should File.
To support my application, I certify that I have attached (you must check both boxes or your application will not be accepted):
A statement of my assets and liabilities at the end of last month (showing book and market values of assets and whether
securities are listed or unlisted), and
An itemized list of my income and expenses for each of the 3 months prior to the due date of the tax.
Signature and Verification
Under penalties of perjury, I declare that I have examined this application, including any accompanying schedules and statements, and to the best of my
knowledge and belief, it is true, correct, and complete; and, if prepared by someone other than the taxpayer, that I am authorized to prepare this form.
Signature of taxpayer
Signature of spouse
Signature of preparer
other than taxpayer
FOR IRS USE ONLY (Do not detach)
This application is
Signature of authorized official
For Privacy Act and Paperwork Reduction Act Notice, see instructions.
Cat. No. 17238O