Form 9465 - Installment Agreement Request

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Installment Agreement Request
OMB No. 1545-1350
(Rev. January 1996)
Department of the Treasury
See instructions below and on back.
Internal Revenue Service
Note: Do not file this form if you are currently making payments on an installment agreement. You must pay your other
Federal tax liabilities in full or you will be in default on your agreement.
If you can’t pay the full amount you owe, you can ask to make monthly installment payments. If we approve your
request, you will be charged a $43 fee. Do not include the fee with this form. We will deduct the fee from your first
payment after we approve your request, unless you choose Direct Debit (see the line 13 instructions). We will usually
let you know within 30 days after we receive your request whether it is approved or denied. But if this request is for
tax due on a return you filed after March 31, it may take us longer than 30 days to reply.
To ask for an installment agreement, complete this form. Attach it to the front of your return when you file. If you
have already filed your return or you are filing this form in response to a notice, see How Do I File Form 9465? on
page 2. If you have any questions about this request, call 1-800-829-1040.
Caution: A Notice of Federal Tax Lien may be filed to protect the government’s interest until you pay in full.
Your first name and initial
Last name
Your social security number
If a joint return, spouse’s first name and initial
Last name
Spouse’s social security number
Your current address (number and street). If you have a P.O. box and no home delivery, show box number.
Apt. number
City, town or post office, state, and ZIP code. If a foreign address, show city, state or province, postal code, and full name of country.
If this address is new since you filed your last tax return, check here
Your home phone number
Best time for us to call
Your work phone number
Best time for us to call
Name of your bank or other financial institution:
Your employer’s name:
City, state, and ZIP code
City, state, and ZIP code
Enter the tax return for which you are making this request (for example, Form 1040). But if you are
filing this form in response to a notice, don’t complete lines 7 through 9. Instead, attach the
bottom section of the notice to this form and go to line 10
Enter the tax year for which you are making this request (for example, 1995)
Enter the total amount you owe as shown on your tax return
Enter the amount of any payment you are making with your tax return (or notice). See instructions
Enter the amount you can paym each month. Make your payments as large as possible to limit interest
and penalty charges. The charges will continue until you pay in full
Enter the date you want to make your payment each month. Do not enter a date later than the 28th
If you would like to make your monthly payments using Direct Debit (automatic withdrawals from your
bank account), check here
Your signature
Spouse’s signature. If a joint return, BOTH must sign.
Privacy Act and Paperwork Reduction Act Notice.—Our
access to the tax information in our files and properly
legal right to ask for the information on this form is Internal
respond to your request. If you do not enter the information,
Revenue Code sections 6001, 6011, 6012(a), 6109, and 6159
we may not be able to process your request. We may give
and their regulations. We will use the information to process
this information to the Department of Justice as provided by
your request for an installment agreement. The reason we
law. We may also give it to cities, states, and the District of
need your name and social security number is to secure
Columbia to carry out their tax laws.
proper identification. We require this information to gain
Cat. No. 14842Y
(Rev. 1-96)


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