Form De 999d - Installment Plan Agreement printable pdf download

Form De 999d - Installment Plan Agreement

INSTALLMENT PLAN AGREEMENT

Log No. _________________

Name ____________________________________

Account Balance __________

DBA _____________________________________

Amount of Offer __________

Account No. _______________________________

Date ___________________

I promise to satisfy the amount offered, by paying the sum of $ __________________ .

I understand that the initial payment of $ ____________ is due on

______________ .

Subsequent installments in the amount of $ _____________ will be paid on the same

day of each succeeding ____________________________ until the entire amount

has been paid in full.

I further understand that failure to pay as promised will result in termination of the Offer

in Compromise, and monies paid to the Department will be applied against the total

liability.

I certify that I have read and fully understand the conditions and terms of this

agreement as stated on the Installment Plan Information Sheet.

By____________________ Title _________________ Date _________________

DE 999D (7-03) (INTERNET)

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Form De 999d - Installment Plan Agreement