Cpp-1 11/10 - Payment Installment Plan Request - Illinois

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Illinois Department of Revenue
CPP-1
Payment Installment Plan Request
Read this information fi rst
Everyone must complete Steps 1, 3, 4, and 5. Complete Step 2 if you are a business requesting a payment installment
plan for a debt other than Individual Income Tax.
If the payment agreement that you are applying for is over $5,000, including penalty and interest, you must also complete
Form EG-13-I, Financial and Other Information Statement for Individuals, or Form EG-13-B, Financial and Other
Information Statement for Businesses.
Step 1: Personal Information
(including your spouse, if applicable)
1
___ ___ ___ - ___ ___ - ___ ___ ___ ___
___ ___ ___ - ___ ___ - ___ ___ ___ ___
Your Social Security number (SSN)
Your spouse’s Social Security number
2
_____________________________________________________________________________________
Your fi rst name and middle initial
Your last name
_____________________________________________________________________________________
Your spouse’s fi rst name and middle initial
Your spouse’s last name
_____________________________________________________________________________________
Your mailing address
_____________________________________________________________________________________
City
State
ZIP
(________)________________________________ (________)__________________________________
Your home phone number
Your work phone number
(________)________________________________
Spouse’s work phone number
Step 2: Identify your business and the person responsible for remitting payments
(businesses only)
3
___ ___ - ___ ___ ___ ___ ___ ___ ___
___ ___ ___ ___ - ___ ___ ___ ___
Federal employer identifi cation number (FEIN)
Illinois account ID
_________________________________
Excise tax number
4
_____________________________________________________________________________________
Business name
_____________________________________________________________________________________
Business mailing address
_____________________________________________________________________________________
City
State
ZIP
________________________________________
(________)__________________________________
Person responsible for remitting payments
Phone number
Department use only
_________________________________________ __________________________________________
Approved by assignee
Approved by supervisor
This form is authorized as outlined by the Illinois Income Tax Act and the Retailers’ Occupation and related occupation taxes and fees acts. Disclosure of this information is
CPP-1 Front (R-11/10)
REQUIRED. Failure to provide information could result in a penalty. This form has been approved by the Forms Management Center. IL-492-4231.

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