Form Ftb 3567bk C2 - Installment Agreement Request

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INSTALLMENT AGREEMENT REQUEST
STATE OF CALIFORNIA
FRANCHISE TAX BOARD
PO BOX 942867
SACRAMENTO CA 94267-0001
Complete this form and mail it to the address shown above. Failure to provide complete information will prevent processing of
your request. DO NOT attach this form to your tax return.
1 Your first name and middle initial
Last name
Social security number
Spouse’s first name and middle initial
Last name
Social security number
Address (number, street, or post office box, and apartment number)
City, State, and ZIP code. If a foreign address, include province, postal code, and full name of country.
2 Home telephone number
3 Work telephone number
4 Spouse’s work telephone number
(
)
(
)
(
)
5
Enter your total account balance for all years ..............................................................................
6 Enter the amount you can pay each month. Interest and penalty charges will continue until you
pay your balance .......................................................................................................................
7 If we approve your request, we agree to let you pay the tax you owe in monthly installments. In
return, you agree to make monthly installments by direct transfer from your bank account.
Enter the date of the month you want your bank to transfer funds to the Franchise Tax Board
Please enter a date between the 1st and the 28th only ..........................................................
1-28 ONLY
8
Name and address of your bank
This is the number at the bottom left of your check. Your bank
9 Bank routing and transit number
can tell you what your routing number is. Please attach a voided
check to this request.
(Please check one:)
10 Checking or savings account number – This must be a regular checking or savings account
Checking
Savings
o
o
I hereby authorize the Franchise Tax Board to initiate and process debit entries to the account identified above. This
authorization will remain in effect until the balance is paid, the Franchise Tax Board cancels the installment agreement, or
the Franchise Tax Board has received and processed written notification from me to stop the debit entries.
I request the amount in box 6 be debited from my account each month on the date specified in box 7. If this day falls on a
Saturday, Sunday, or a holiday, the transfer is authorized for the next business day.
If the Franchise Tax Board cannot deduct the monthly payment from my account because of insufficient funds or because
the account is closed, the Franchise Tax Board may cancel this installment agreement. The Franchise Tax Board will
charge me a dishonored payment penalty and may charge me a collection fee. I will be responsible for any overdraft fees
charged by my bank.
Your signature
Date
If a joint return, spouse’s signature
Date
This signature is only required if the owner of the account is
Bank account owner’s signature
Date
someone other than the taxpayer or spouse.
If you have questions about your installment agreement, please call (916) 845-4470. Our Interactive Voice Response
system is available seven days a week, 24 hours a day. Our representatives are available Monday through Friday 8 a.m. to
5 p.m. If you are hearing impaired, TDD services are available at (800) 822-6268.
FTB 3567BK C2 (REV 09-2000)

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