Form 40 Pa - Idaho Payment Agreement Request - For Individual Income Tax Due - 2003
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Idaho Payment Agreement Request
40 PA
F
O
R
M
For Individual Income Tax Due
TC40PA
11-04-03
Do not attach this form to your tax return. Mail it in a separate envelope to Attn: 40PA, Idaho State Tax Commission, P O Box 36, Boise ID 83722-0410
SECTION 1
Your first name and middle initial
Last name
Your Social Security number
If a joint return, spouse’s first name and middle initial
Last name
Spouse’s Social Security number
Your current address (number, street, and apartment number)
City, post office box, state and ZIP code
Home phone
Your work phone
Spouse's work phone
Your cell phone
Spouse's cell phone
Type of account (check one):
Checking
Savings
Tax year(s):
Preferred date of month
Total amount owed:
5th
20th
Both
for the withdrawal:
Name of bank or
Amount you can pay each payment: $
financial institution:
Routing number (see back):
Account number (see back):
SECTION 2
Required for verification of account and routing numbers for automatic withdrawal of payments.
• Attach a voided check for withdrawal from a checking account;
OR
• Attach a deposit slip for withdrawal from a savings account;
OR
• Attach a letter from your bank verifying your account type, account number, and routing number.
SECTION 3
Please read this important information.
•
If you incur an additional Idaho tax debt while in this payment agreement, your agreement will be cancelled and a tax lien will be
filed on all years not paid.
•
Any future state and federal refunds you are due may be applied to your tax debt, and will not take the place of your regular payment.
As long as you do not default on this agreement, the Tax Commission will not pursue other collection actions, which may include
seizure of assets.
•
Please check your withholding exemptions on your W-4 form(s). You may need to contact your employer and decrease the number
of exemptions you are claiming, so enough will be withheld from your wages to cover your tax debt in the future.
SECTION 4
I have read the front and back of this form and understand the requirements of this program. I acknowledge and understand my
responsibilities and the actions that may be pursued by the Idaho State Tax Commission regarding my payment agreement.
Your signature
Date
Spouse’s signature if filing jointly
Date
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