Form Tc-804 - Individual Income Tax Payment Agreement Request
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Utah State Tax Commission
TC-804
Individual Income Tax
Rev. 4/13
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 801-297-7703 or 1-800-662-4335, ext. 7703
Your social security number
Your full name (first, middle, last)
Spouse's social security number
If a joint return, spouse's full name (first, middle, last)
Your current address
Daytime telephone number
Evening telephone number
Email address (required for pay plan reminders)
Your employer(s) name, address and telephone number
Spouse’s employer(s) name, address and telephone number
TIP: If you are submitting this form in response to a billing notice, do not complete lines 1 through 3.
Instead, attach the bottom section of the billing notice to this form and complete lines 4 through 6.
1. Enter the income tax year for which you are making this request (example, “2011”)
2. Enter the total amount you owe as shown on your income tax return
$
3. 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.
4. Enter the amount you can pay each month. Your payment should be large enough to pay off
$
the tax due, penalty and interest within 24 months. Late filing, late payment 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
incometax.utah.gov
.
5. 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.
6. You must have filed income tax returns for all prior years before your pay
plan
will be approved.
If you have not, list the year(s) not filed and date you will be filing the returns.
Note: To enter into a pay plan you must file and pay future taxes on time and make your monthly pay plan payments to
the Tax Commission by the due date. If you do not meet these conditions, you default on your pay plan and are subject
to additional penalty, interest and fees. The Tax Commission may also record liens, garnish your wages and bank accounts,
take and sell your property, or refer your account to a collection agency.
I have read and understand the requirements of this request.
Date
Date
Your signature
Spouse’s signature (if joint return, both must sign)
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.
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