12-Month Personal Income Tax Installment Agreement Request Form
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Complete 12-Month Personal Income Tax Installment Agreement Request Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
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12-Month Personal Income Tax Installment Agreement Request Form
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First Name
Middle Initial
Last Name
Social Security Number
___________________________________________________________ ______________________________
YES NO
Is this a joint return?
Spouse’s information, if applicable:
First Name
Middle Initial
Last Name
Social Security Number
___________________________________________________________ ______________________________
Home Address
__________________________________________________________________________________________
City, State and Zip Code
WV
__________________________________________________________________________________________
YES NO
Did this address change since you last filed?
Daytime Phone Number______ __________________ Home Phone Number ______ __________________
Please list the Letter ID number from the notice you received _____________________________________
Please enter your account number as shown on the notice __________________________________
Enter total amount you owe as shown on notice __________________________________________
Enter total number of months you are requesting for the installment payment agreement.*
____ months (Remember, you cannot exceed twelve months.)
th
*Your first installment payment will be due the 15
of the month following submission of this form.
By signing this payment installment form, you are agreeing that your balance due is correct; that you will continue to file
state tax return(s) and pay any additional state tax due in a timely manner during the term of agreement; and that you
will make timely monthly payments until your tax liability, including interest and penalties, is paid in full.
Your signature
Date
Spouse’s Signature
Date
___________________________________________
__________________________________________
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Parent category: Financial