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Utah State Tax Commission
TC-405
Miscellaneous Tax
Rev. 8/10
Payment Agreement Request
Get forms online - tax.utah.gov
DO NOT use this form if you are currently making payments on an existing payment agreement. Instead, call 801-297-3566 or 1-800-662-4335, ext. 3566.
DO NOT mail with your tax return. To insure proper processing, mail separately to: Miscellaneous Tax, 210 N 1950 W, SLC, UT 84134-3500.
Business or individual name (first, middle initial, last)
EIN or social security number
Current address
Contact name
Daytime telephone number
List all tax types and account numbers related to the payment agreement
$
$
Tax type
Amount
Tax type
Amount
$
$
Tax type
Amount
Tax type
Amount
TIP: If you are submitting this form in response to a billing notice, do not complete lines 1 through 4.
Instead, attach the bottom section of the billing notice to this form and complete lines 5 through 6.
1. Enter the tax return form number or audit type for which you are making this
request (example, “TC-563” or cigarette/tobacco audit)
2. Enter the tax year or period for which you are making this request
(example, “2009” or “Apr - Jun 2009 Qtr”)
3. Enter the total amount you owe as shown on your tax return or billing notice
$
4. Enter the amount of any payment you are making with your tax return or notice
$
Make your payment as large as possible to limit penalty and interest charges.
5. Enter the amount you can pay each month. Minimum payment requirements are:
$
a. If you are an individual or the business is a sole proprietor or partnership, the payment
should be large enough to pay off the tax due, penalty and interest within 24 months.
b. If the business is a corporation, S-Corporation, LLC or LLP and the tax amount due is:
i. less than $5,000, your payment should be large enough to pay off the tax due, penalty
and interest within 24 months (minimum payment $25).
ii. equal to or greater than $5,000, three equal payments - if unable to pay in-full in
90 days, contact the Tax Commission for further instructions.
Make your payment as large as possible to limit penalty and interest charges. Late filing, late payments
and extension penalties may apply. Interest will be assessed and continue to accrue until the amount
owed is paid in full. Penalty and interest information is available online at
tax.utah.gov
.
6. Enter the day of the month you want your payments to be due (example, “5th day” of
each month). Your payment must be received on or before the payment due date.
This agreement is not binding until signed.
I have read and understand the requirements of this request.
Authorized signature
Date
If you need an accommodation under the Americans with Disabilities Act, contact the Tax Commission at 801-297-3811
or Telecommunications Device for the Deaf 801-297-2020. Please allow three days for a response.