Instructions For Form 9465 (Rev. December 2012) (Page 3 of 3) in pdf

Line 8

boxes blank. On the sample check below, the account number is

20202086. Do not include the check number.

Even if you cannot pay the full amount you owe now, you should pay

as much as possible to limit penalty and interest charges. If you are

Note. We may have filed a notice of federal tax lien against your

filing this form with your tax return, make the payment with your

property. If so, you may be able to get the notice of lien withdrawn.

return. For details on how to pay, see your tax return instructions.

To learn more about lien withdrawals and to see if you qualify, visit

IRS.gov and enter "lien withdrawal" in the search box.

If you are filing this form by itself, such as in response to a notice,

attach a check or money order payable to “United States Treasury.”

The electronic funds transfer (EFT) from your checking

Do not send cash. Be sure to include:

account will not be approved unless you (and your spouse

TIP

Your name, address, SSN/EIN, and daytime phone number.

if filing a joint return) sign Form 9465.

The tax year and tax return (for example, “2011 Form 1040”) for

which you are making this request.

Sample Check—Lines 11a and 11b

Line 9

Paul Maple

1234

SAMPLE

Roberta Maple

Enter on line 9 the amount you can pay each month. Make your

123 Pear Lane

15-0000/0000

Anyplace, VA 20000

payments as large as possible to limit interest and penalty charges.

The charges will continue until you pay in full. If no payment amount

PAY TO THE

is listed on line 9, a payment will be determined for you by dividing

ORDER OF

Routing

Account

the balance due by 72 months.

number

DOLLARS

(line 11a)

(line 11b)

ANYPLACE BANK

Line 10

Do not include

Anyplace, VA 20000

the check number.

You can choose the day of each month your payment is due. This

For

can be on or after the 1st of the month, but no later than the 28th of

:250250025

:202020"'86".

1234

the month. For example, if your rent or mortgage payment is due on

the 1st of the month, you may want to make your installment

The routing and account numbers may be in different

payments on the 15th. When we approve your request, we will tell

places on your check.

TIP

you the month and day that your first payment is due.

If we have not replied by the date you chose for your first

Privacy Act and Paperwork Reduction Act Notice. Our legal

payment, you can send the first payment to the Internal Revenue

right to ask for the information on this form is sections 6001, 6011,

Service Center at the address shown earlier that applies to you. See

6012(a), 6109, and 6159 and their regulations. We will use the

the instructions for line 8 above for details on what to write on your

information to process your request for an installment agreement.

payment.

The reason we need your name and social security number is to

Lines 11a and 11b

secure proper identification. We require this information to gain

access to the tax information in our files and properly respond to

Making your payments by electronic funds Transfer (EFT)

your request. You are not required to request an installment

will help ensure that your payments are made timely and

agreement. If you do request an installment agreement, you are

TIP

that you are not in default of this agreement.

required to provide the information requested on this form. Failure to

provide this information may prevent processing your request;

To pay by electronic funds transfer (EFT) from your checking

providing false information may subject you to fines or penalties.

account at a bank or other financial institution (such as a mutual

fund, brokerage firm, or credit union), fill in lines 11a and 11b. Check

You are not required to provide the information requested on a

with your financial institution to make sure that an EFT is allowed

form that is subject to the Paperwork Reduction Act unless the form

and to get the correct routing and account numbers.

displays a valid OMB control number. Books or records relating to a

form or its instructions must be retained as long as their contents

If the total amount you owe is greater than $25,000 but not

may become material in the administration of any Internal Revenue

more than $50,000, you must agree to an Electronic Funds

law. Generally, tax returns and return information are confidential, as

Transfer (EFT) Agreement to qualify for an Installment

required by section 6103. However, we may give this information to

CAUTION

Agreement (IA) without completing a financial statement. If you do

the Department of Justice for civil and criminal litigation, and to

not agree to a DDIA, you must complete Form 433-F, Collection

cities, states, the District of Columbia, and U.S. commonwealths and

Information Statement, and mail it with this form.

possessions to carry out their tax laws. We may also disclose this

information to other countries under a tax treaty, to federal and state

Line 11a. The routing number must be nine digits. The first two

agencies to enforce federal nontax criminal laws, or to federal law

digits of the routing number must be 01 through 12 or 21 through 32.

enforcement and intelligence agencies to combat terrorism.

Use a check to verify the routing number. On the sample check on

this page, the routing number is 250250025. But if your check is

The average time and expenses required to complete and file

payable through a financial institution different from the one at which

this form will vary depending on individual circumstances. For the

you have your checking account, do not use the routing number on

estimated averages, see the instructions for your income tax return.

that check. Instead, contact your financial institution for the correct

If you have suggestions for making this form simpler, we would

routing number.

be happy to hear from you. See the instructions for your income tax

Line 11b. The account number can be up to 17 characters (both

return.

numbers and letters). Include hyphens but omit spaces and special

symbols. Enter the number from left to right and leave any unused

-3-

Instructions For Form 9465 (Rev. December 2012) Page 3

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