Form 9465 - Installment Agreement Request Page 2
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Form 9465 (Rev. 1-2018)
Page
Part II
Additional information. Complete this part only if all 3 conditions apply:
1. you defaulted on an installment agreement in the past 12 months,
2. you owe more than $25,000 but not more than $50,000, and
3. the amount on line 11a (or 11b, if applicable) is less than line 10.
Note: If you owe more than $50,000, complete and attach Form 433-F, Collection Information Statement.
15
In which county is your primary residence?
16a Marital status:
Single. Skip question 16b and go to question 17.
Married. Go to question 16b.
b Do you share household expenses with your spouse?
Yes.
No.
17
How many dependents will you be able to claim on this year's tax return?.
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17
18
18
How many people in your household are 65 or older?
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19
How often are you paid?
Once a week.
Once every two weeks.
Once a month.
Twice a month.
20
What is your net income per pay period (take home pay)? .
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20
$
Note: Complete lines 21 and 22 only if you have a spouse and meet certain conditions (see instructions). If you don't
have a spouse, go to line 23.
21
How often is your spouse paid?
Once a week.
Once every two weeks.
Once a month.
Twice a month.
22
What is your spouse's net income per pay period (take home pay)? .
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22
$
23
23
How many vehicles do you own? .
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24
How many car payments do you have each month? . . . . . . . . . . . . . . . . . . .
24
25a Do you have health insurance?
Yes. Go to question 25b.
No. Skip question 25b and go to question 26a.
b Are your health insurance premiums deducted from your paycheck?
Yes. Skip question 25c and go to question 26a.
No. Go to question 25c.
c How much are your monthly health insurance premiums? .
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25c
$
26a Do you make court-ordered payments?
Yes. Go to question 26b.
No. Go to question 27.
b Are your court-ordered payments deducted from your paycheck?
Yes. Go to question 27.
No. Go to question 26c.
c How much are your court-ordered payments each month?
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26c
$
27
Not including any court-ordered payments for child and dependent support, how much do you pay
27
for child or dependent care each month?
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$
9465
Form
(Rev. 1-2018)
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