Fillable Form 40pa - Idaho Payment Agreement Request printable pdf download

40PA

Idaho Payment Agreement Request

EFO00046 11-05-12

For Individual Income Tax Due

Do not attach this form to your tax return. Mail it in a separate envelope to Attn: 40PA, Idaho State Tax Commission, PO Box 36, Boise ID 83722-0410

SECTION 1

Your first name and initial

Last name

Your Social Security number

If a joint return, spouse’s first name and initial

Last name

Spouse’s Social Security number

Mailing address (number, street, and apartment number)

City, state, and Zip code

Home phone

Your work phone

Spouse’s work phone

Your cell phone

Spouse’s cell phone

Your email address

Spouse’s email address if different

Type of account (check one):

Checking

Savings

Tax year(s):

Preferred day of month

5th

20th

Both

Total amount due:

for the withdrawal:

Name of bank or

Amount you can pay each payment:

financial institution:

Account number (see page 2):

Routing number (see page 2):

SECTION 2

To verify account and routing numbers for automatic withdrawal of

Attach

payments, attach one of the following:

bank

 A voided check for withdrawal from a checking account.

 A deposit slip for withdrawal from a savings account.

verification

 A letter from your bank verifying your account type, account

number, and routing number.

here.

All owners of the bank account must sign this Form 40PA.

SECTION 3 - Please read.

 This is a one-time payment agreement program. You must file and pay future taxes on time, or we will cancel this

agreement and begin collection action. This may include a levy on your wages or bank accounts, or seizure of assets.

 We will file a state tax lien to protect the state’s interest. (See page 2 for more details.)

 Any future state and federal refunds you are due may be applied to your debts and will not take the place of your regular

payment.

 As long as you do not default on this agreement, the Tax Commission will not pursue collection action.

 Please check your withholding exemptions on your W-4 form(s). You may need to contact your employer and decrease the

number of exemptions you are claiming, so enough will be withheld from your wages to cover your tax debt in the future.

 By entering into this agreement, you agree to pay all tax, penalty, and interest related to this debt.

SECTION 4

I have read the front and back of this form and understand the requirements of this program. I acknowledge and understand

my responsibilities and the actions that the Idaho State Tax Commission may pursue regarding my payment agreement.

Spouse’s signature, if filing jointly

Your signature

Date

If the person(s) listed in SECTION 1 are different than the owner(s) of the bank account, the owner(s) of the bank account must sign:

Owner of bank account

Date

Other owner of bank account, if applicable

Date

Form 40pa - Idaho Payment Agreement Request

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