Form Ftb 3567 C2 - Installment Agreement Request

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State of California
Franchise Tax Board
Installment agreement request
Complete this form and mail it to the address shown on PAGE 1. Failure to provide complete information will delay the
processing of your request. Do not attach this form to your tax return. Caution: Do not use this form if you are currently
making payments on an installment agreement. Instead, call 800.689.4776.
If you are making this request for a joint liability, print the names and social security numbers (SSNs) or FTB IDs in the
same order as on your California state tax return.
First Name
M.I. Last Name
SSN or FTB ID (required)
If Joint, Spouse’s/RDP’s
First Name
M.I. Last Name
Spouse’s/RDP’s SSN or FTB ID
1
Current Home Address-Number and Street, PO Box, or Rural Route.
Apt. No.
PMB No.
City, Town, or Post Office
State
ZIP Code
Home Phone Number
Work Phone Number
Spouse’s/RDP’s Work Phone Number
(
) _____________________________
(
) ____________________ Ext. ________
(
) ____________________ Ext. ________
If we approve your request, we agree to let you pay the tax you owe in monthly installments instead of immediately paying
the amount in full. In return, you agree to make your monthly payments timely.
EFT Authorization
I authorize an electronic funds withdrawal for the amount in box 1, from the account identified below, on the ________
(please specify) day of the month. The day must be the 1st through the 28th. If this day falls on a Saturday, Sunday, or
holiday, the transfer is authorized for the next business day.
1. Payment
2. Day for Monthly EFT
3. Bank Routing Number
4. Bank Account Number
Amount
Withdrawal
(Enter the date from above.)
(This is the first nine-digit number at the bottom left of your check.)
(This is the number after the bank routing number.)
5. Bank Name and Address
Check One:
Checking 
Savings 
(This must be a regular checking or savings account.)
I certify that I have the authority to request an electronic funds withdrawal from the bank account identified above and I
authorize the Franchise Tax Board (FTB) to initiate and process electronic funds withdrawal entries to the above account.
This authorization remains in effect until: 1) all unpaid tax liabilities due or becoming due during the course of this
agreement are paid, 2) FTB cancels the installment agreement, or 3) FTB receives written notice of cancellation of this
EFT Authorization within five business days prior to the payment due date.
I request that the payment amount in box 1 be debited from my bank account each month on the date specified in box 2. If
this day falls on a Saturday, Sunday, or state holiday, I authorize the transfer for the next business day.
If FTB cannot deduct the monthly payment from my bank account because of insufficient funds or because my account
is closed, FTB may cancel my installment agreement. In that event, I understand that FTB may charge me a dishonored
payment penalty and a collection fee. I will also be responsible for any overdraft fees charged by my bank.
Authorized Signature
Signer’s Name (print)
Daytime Telephone Number and Ext. Date
By initialing the box below you agree to the following statement:
I have read and agree to the taxpayer installment agreement conditions on PAGE 1 and if my balance is greater
than $10,000 or payment is over 36 months, I certify I have a financial hardship.
RDP refers to a registered domestic partner or partnership.
1
FTB 3567 C2 (REV 12-2009) PAGE 2

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