Instructions For Form 9465-Fs - Installment Agreement Request (Page 3 of 3) in pdf

Line 8

The electronic funds withdrawal from your checking account

will not be approved unless you (and your spouse if filing a

TIP

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

joint return) sign Form 9465-FS.

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

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

Sample Check — Lines 11a and 11b

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

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

notice, attach a check or money order payable to the “United States

SAMPLE

Paul Maple

1234

Treasury.” Do not send cash. Be sure to include:

Roberta Maple

•

15-0000/0000

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

123 Pear Lane

•

Anyplace, VA 20000

The tax year and tax return (for example,“ 2009 Form 1040”) for

which you are making this request.

PAY TO THE

Line 9

ORDER OF

Routing

Account

number

DOLLARS

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

(line 11a)

(line 11b)

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

ANYPLACE BANK

Do not include

Anyplace, VA 20000

The charges will continue until you pay in full. If a payment amount

the check number.

is not shown on line 9, one will be determined for you by dividing

For

the balance due by 72 months.

:250250025

:202020"'86". 1234

Line 10

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

The routing and account numbers may be in different places

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

on your check.

TIP

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

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

Part II

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

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

Lines 12—24

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

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

Complete Part II only if your balance due is greater than $25,000

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

but not more than $50,000.

your payment.

Privacy Act and Paperwork Reduction Act Notice. Our legal

Lines 11a and 11b

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

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

Making your payments by electronic funds withdrawal will

information to process your request for an installment agreement.

help ensure that your payments are made timely and that

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

TIP

you are not in default of this agreement.

secure proper identification. We require this information to gain

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

To pay by electronic funds withdrawal from your checking

your request. You are not required to request an installment

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

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

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

required to provide the information requested on this form. Failure

your financial institution to make sure that an electronic funds

to provide this information may prevent processing your request;

withdrawal is allowed and to get the correct routing and account

providing false information may subject you to fines or penalties.

numbers.

You are not required to provide the information requested on a

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

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

more than $50,000, you must agree to a Direct Debit

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

Installment Agreement (DDIA) to qualify for an IA without

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

CAUTION

completing a financial statement. If you do not agree to a DDIA, you

may become material in the administration of any Internal Revenue

must complete Form 433-F, Collection Information Statement, and

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

mail it with this form.

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

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

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

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

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

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

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

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

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

payable through a financial institution different from the one at

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

which you have your checking account, do not use the routing

law enforcement and intelligence agencies to combat terrorism.

number on that check. Instead, contact your financial institution for

The average time and expenses required to complete and file

the correct routing number.

this form will vary depending on individual circumstances. For the

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

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

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

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

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

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

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

return.

20202086. Do not include the check number.

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

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

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

IRS.gov and enter ‘‘lien withdrawal’’ in the search box.

-3-

Instructions For Form 9465-Fs - Installment Agreement Request Page 3

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