Form Ga-9465 - Installment Payment Agreement Request
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1Installment Payment Office
Form GA-9465 (10/06)
(404) 417- 6486
(404) 417- 4491 (Fax)
State of Georgia
ipa@dor.ga.gov
Department of Revenue
1800 Century Blvd., Ste. 18325
FOR OFFICE USE ONLY
Atlanta, Georgia 30345
INSTALLMENT PAYMENT AGREEMENT REQUEST
1.
Your First Name and Initial
Last Name
Your Social Security Number
Spouse’s First Name and Initial (If you filed a joint return)
Last Name
Spouse’s Social Security Number
Your Address
Apartment Number
City, Town or Post Office, State, and ZIP Code
Home Phone Number
2.
Check here if this address has changed since your last tax return.
3.
Your Employer:
Spouse’s Employer
Address
Address
City, State, and ZIP Code
City, State, and ZIP Code
Phone Number
Phone Number
4.
Enter the tax year(s) for which you are making this request.
_______________________
5.
Enter the state tax execution number, if applicable:
_______________________
6.
Enter the total amount you owe as shown on your tax return or notice: . . . . . . . . .
6.
7.
Enter the amount of payment you are making with this request: .
. . . . . . . . . . .
7.
8.
Name of your bank or financial institution
Address
City, State, and ZIP Code
9.
Please see the reverse side of this form for instructions:
a.
Routing Number:
b.
Account Number:
I authorize the Georgia Department of Revenue and its designated Financial Agent to initiate a monthly ACH
electronic funds withdrawal entry to the financial institution account indicated for payment of my State taxes
owed, and the financial institution to debit the entry to this account. This authorization is to remain in full force
and effect until I notify the Agent for the Georgia Department of Revenue to terminate the authorization. To
revoke payment, I must contact the Georgia Department of Revenue Agent at (404) 417- 6486 no later than 7
business days prior to the payment (settlement) date. I also authorize the financial institutions involved in the
processing of the electronic payments of taxes to receive confidential information necessary to answer
inquiries and resolve issues related to the payments.
Your Signature
Date
Spouse’s Signature.
Date
(If a joint return, both must sign.)
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Parent category: Financial