Form Ga-9465 - Installment Agreement Request Page 3
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GA-9465
(Rev. 2/2013)
Form
Specific Instructions
To avoid processing delays,
•
Line 8a
Provide all requested information. If you are making
this
The routing number must be nine digits. The first two digits of
request for a joint tax return, show the names and social
the routing number must be 01 through 12 or 21 through 32.
security numbers (SSNs) in the same order as on your tax
Use a check to verify the routing number. On the sample
return. If you are making this request for a business, show
the name of the person responsible for paying any sales or
check on this page, the routing number is 250250025. But if
your check is payable through a financial institution do not use
withholding taxes and the related social security numbers on
the routing number on that check. Instead, contact your
line 3.
financial institution for the correct routing number.
Do not
use the routing number indicated on your deposit slip.
Line 1
If you received a notice from the Department showing an
Line 8b
amount due, enter the Letter ID listed on the notice. Doing so
The account number can be up to 17 characters (both
will help the Department process your request.
numbers and letters). Include hyphens but omit spaces and
Line 2
special symbols. Enter the number from left to right and leave
any unused boxes blank. On the sample check below, the
Check the box to identify the tax type for the installment
payment agreement request and the corresponding tax identifi-
account number is 20202086. Do not include the check
cation number.
number.
Line 4
Enter the total amount you owe as shown on your tax return
or notice.
Line 5
Enter the total number of months subject to the installment
payment agreement not to exceed 36 months.
Line 6
Enter the amount you can pay each month. Interest and
(line 8a)
(line 8b)
penalties will continue to accrue until you pay in full.
Line 7
Enter the day your monthly payment will be debited from your
bank account (1st to the 28th).
Line 9
You (or in the case of a business, the person responsible for
Line 8
remitting payments) must sign the statement. This signature
In order to pay by electronic funds withdrawal from your check-
authorizes the Georgia Department of Revenue to use the
ing account at a bank or other financial institution (such as
information on this form to make monthly withdrawals from the
mutual fund, brokerage firm, or credit union), you must fill in all
account listed in Line 8. This authorization remains in force
information requested in line 8. Check with your financial
until the Department receives written notification from you.
institution to make sure that an electronic funds withdrawal is
Your signature also acknowledges that you have waived all
allowed and to get the correct routing and account numbers.
rights of any additional notice, refund, or appeal concerning
Attach a blank check to your installment payment request and
the assessment and collection of any part or all of the tax
mark “VOID” across the front.
liability to be paid by means of this installment agreement
request.
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