Form 1127-A - Application For Extension Of Time For Payment Of Income Tax For 2011 Due To Undue Hardship - 2011 Page 4
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Form 1127-A (2011)
Part I. Eligibility Requirements
Privacy Act and Paperwork Reduction Act Notice. We ask for
the information on this form to carry out the Internal Revenue laws
Filing Status. Check the box indicating the filing status you are
of the United States. We need this information to ensure
claiming on your 2011 Form 1040, Form 1040A, or Form 1040EZ.
compliance with these laws and to properly grant extensions of
Adjusted Gross Income. Enter your adjusted gross income (AGI)
time to pay tax. Applying for an extension of time for the payment of
from your 2011 Form 1040, line 37 (Form 1040A, line 21, or Form
tax is voluntary. However, providing the requested information is
1040EZ, line 4).
mandatory if you apply for the extension. Our legal right to ask for
the information requested on this form is based in sections 6001,
Note. To qualify for this extension, your AGI must be less than
6011, 6109, and 6161 and their regulations. If you fail to provide all
$100,000 ($200,000 if married filing jointly).
or part of the information requested, your application may be
Amount you owe. Enter the amount you owe from your 2011 Form
denied. If you provide false or fraudulent information, you may be
1040, line 76 (Form 1040A, line 45, or Form 1040EZ, line 12).
subject to penalties.
Note. You must owe less than $50,000 to qualify for this extension.
You are not required to provide the information requested on a
Part II. Reason for Extension
form that is subject to the Paperwork Reduction Act unless the
Check the appropriate box indicating the reason you need an
form displays a valid OMB control number. Books or records
extension of time to pay your 2011 income tax liability.
relating to a form or its instructions must be retained as long as
their contents may become material in the administration of any
Part III. Terms for Granting the Extension
Internal Revenue law. Generally, tax returns and return information
are confidential, as required by section 6103. However, section
Failure to pay the full amount by the payment extension date.
6103 allows or requires the Internal Revenue Service to disclose
You will receive a notice and demand for payment that is
the information to others as described in the Code. For example,
automatically generated when you file your return and the amount
we may disclose this information to the Department of Justice for
shown due on the return is assessed. You may disregard the
enforcement of civil or criminal tax laws; to cities, states, the
payment due date on that notice unless the IRS notifies you that
District of Columbia, and U.S. commonwealths or possessions to
your request for an extension of time has not been approved.
administer their tax laws; to other countries under a tax treaty; to
Signature and Verification
federal and state agencies to enforce non-tax criminal laws; or to
federal law enforcement and intelligence agencies to combat
This form must be signed and dated.
terrorism.
If this application is for the income tax shown on a joint return,
The time needed to complete and file this form will vary
both you and your spouse must sign and date this form. If your
depending on individual circumstances. The estimated burden for
spouse cannot sign, see Pub. 501.
taxpayers who file this form is shown below.
Contacting the IRS
Recordkeeping .
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6 min.
If you have questions regarding your eligibility for an extension of
Learning about the
time to pay, please call our toll-free number at 1-800-829-1040
law or the form .
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. 15 min.
(hearing impaired customers with access to TTY/TDD equipment
Preparing and sending
may call 1-800-829-4059) or visit our website at
the form to the IRS .
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. 58 min.
If you have comments concerning the accuracy of these time
Ordering Forms and Publications
estimates or suggestions for making this form simpler, we would
be happy to hear from you. See the instructions for the tax return
You can get forms and publications by calling 1-800-TAX-FORM
for which this form is filed.
(1-800-829-3676), or by visiting your local IRS office or our website
at IRS.gov.
Low Income Taxpayer Clinics
Low Income Taxpayer Clinics (LITCs) are independent from the IRS.
Some clinics serve individuals whose income is below a certain
level and who need to resolve a tax problem. These clinics provide
professional representation before the IRS or in court on audits,
appeals, tax collection disputes, and other issues for free or for a
small fee. Some clinics can provide information about taxpayer
rights and responsibilities in many different languages for individuals
who speak English as a second language. For more information and
to find a clinic near you, see the LITC page on
or IRS Publication 4134, Low Income
Taxpayer Clinic List. This publication is also available by calling
1-800-829-3676 or at your local IRS office.
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