Form Cpp-1 - Payment Installment Plan Request - Illinois Department Of Revenue
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1Illinois Department of Revenue
CPP-1
Payment Installment Plan Request
Read this information first
Please read the instructions before completing this form.
Everyone must complete Parts 1, 2, 3, and 5. Complete Part 4 if you are a business requesting a payment installment plan for a debt other
than Individual Income Tax.
Part 1:
Identify your unpaid liability and the amount you want to pay each month
1
Have all tax returns been filed?
___ Yes
___ No
(See instructions.)
If you answered “No,” you must complete and attach all returns that you have not filed to
this form. If you do not, we cannot consider your request. Identify the tax return and the
periods covered for all returns that you are now filing. _____________________________
_______________________________________________________________________
2
Total amount of your unpaid tax liability.
(See instructions. If the amount is more than $5,000, you
must complete and attach either Form EG-13-B or Form EG-13-I.)
2
$___________________________________
3
3
Identify all tax periods for which the liability on Line 2 exists.
___________________________________
4
4
Write the amount you would like to pay each month.
$___________________________________
(See instructions.)
5
5
Write the date or dates
of each month that you want to make your payment.
___________________________________
(1st to the 28th)
Part 2:
Identify your financial institution and account information
6
9
_______________________________________________________________________
____________________________________
Financial institution’s name
Account number
(regular checking or savings account)
7
10
_______________________________________________________________________
Account type:
Checking
Savings
Address
City
State
ZIP
8
11
_______________________________________________________________________
___ ___ ___ ___ ___ ___ ___ ___ ___
Names on the account
Bank routing and transit number from the bottom
(list all names)
of your check (for checking accounts) or contact
your financial institution for the routing number (for
savings accounts)
Part 3:
Identify yourself (and your spouse, if applicable)
12
16
_______________________________________________________________________
___ ___ ___ — ___ ___ — ___ ___ ___ ___
Your first name
Middle initial
Last name
Your social security number
13
17
_______________________________________________________________________
___ ___ ___ — ___ ___ — ___ ___ ___ ___
Spouse’s first name
Middle initial
Last name
Spouse’s social security number
(
)
—
14
18
_______________________________________________________________________
____________________________________
Address
City
State
ZIP
Your work phone number
(include apartment number or P.O. box)
(
)
—
(
)
—
15
19
____________________________________
____________________________________
Your home phone number
Spouse’s work phone number
Part 4:
Identify your business and the person responsible for remitting payments
(Businesses only)
20
23
_______________________________________________________________________
___ ___ — ___ ___ ___ ___ ___ ___ ___
Business name
Federal employer identification number (FEIN)
21
24
_______________________________________________________________________
___ ___ ___ ___ — ___ ___ ___ ___
Address
City
State
ZIP
Illinois Business Tax (IBT) number
(include suite number or P.O. box)
(
)
—
22
25
_______________________________________________________________________
____________________________________
Person responsible for remitting payments
Phone
Excise Tax number
Part 5:
Read the statement and sign below
I agree to pay the amount on Line 4 each month on the date or dates specified on Line 5. I understand that, if the department does not agree to the
proposed payment amount on Line 4, additional information about my financial condition may be requested and I may be required to pay a higher
amount. In addition, I understand that I must complete Form EG-13-B or Form EG-13-I if my liability is over $5,000, and that liens may be filed
at the department’s discretion. I will make all payments as scheduled and I will file all future required returns and pay any tax owed for those
periods. If I do not remit the scheduled payment, and file all required returns, my payment installment plan may be canceled; the entire unpaid balance
will become due immediately; and enforcement action may be taken, which could include levy of my bank account or wages.
Under penalties of perjury, I state that I have examined this form and, to the best of my knowledge, it is true, correct, and complete.
_____________________________________________________________________________________________________________________
Your signature
Date
Department use only
_____________________________________ _____________________________________
Approved by assignee
Approved by supervisor
This form is authorized as outlined by the Illinois Income Tax Act and the Retailers’ Occupation and related occupation taxes and fees acts. Disclosure of this
information is REQUIRED. Failure to provide information could result in a penalty. This form has been approved by the Forms Management Center. IL-492-4231
CPP-1 front (R-10/01)
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