Deferred Payment Request Form - New Jersey Division Of Taxation
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1DEFERRED PAYMENT REQUEST FORM
FILL OUT THIS SECTION IF YOU ARE REQUESTING A PAYMENT PLAN FOR YOUR INDIVIDUAL TAXES
Name:
Last
First
Address:
Street Address
Apartment/Unit #
City
State
ZIP Code
Home Phone:
(
)
Daytime Phone:
(
)
E-mail Address:
Primary Social Security Number :
Secondary Social Security Number :
FILL OUT THIS SECTION IF YOU ARE REQUESTING A PAYMENT PLAN FOR YOUR BUSINESS
Business name:
NJ Registration # / FEIN:
Address:
Street Address
Apartment/Unit #
City
State
ZIP Code
Business Phone:
(
)
Alternate Phone:
(
)
E-mail Address:
Responsible Officer(s) __________________________________ Social Security Number ______________________________________
Use additional sheets if necessary
CONTACT INFORMATION IF DIFFERENT FROM ABOVE
Name:
Last
First
Address:
Street Address
Apartment/Unit #
City
State
ZIP Code
Primary Phone:
(
)
Alternate Phone:
(
)
PAYMENT INFORMATION
Amount of Debt:
$
Amount of Monthly Payment:
$
Day of Month Payment Due:
E
All request forms will be reviewed by the New Jersey Division of Taxation Deferred Payment Section and are subject to change.
Taxpayer Signature
Date
Type of Plan Requested:
SEND COMPLETED FORM TO:
□ Business
NEW JERSEY DIVISION OF TAXATION
□ Personal Income Tax
DEFERRED PAYMENT CONTROL CENTER
□ Rebate Program
PO BOX 190
□ Cigarette
_______________________
TRENTON, NJ 08695-0190
( File #)
□ Other _______________________________
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