Form Uc-010 - Installment Payment Agreement
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2ARIZONA DEPARTMENT OF ECONOMIC SECURITY
UC-010-FF (8-17)
Page 1 of 2
Employer Engagement Administration
Unemployment Tax, MD 5881 • P.O. Box 6028 • Phoenix, Arizona 85005-6028
Phone: (602) 771-6604
INSTALLMENT PAYMENT AGREEMENT
Employer’s Name
Date
Account Number
I agree and do admit that unemployment taxes, accrued interest, and penalties for periods beginning
and ending
, in the total amount of $
are due and unpaid as of this date to the
Arizona Department of Economic Security (department).
I further understand that interest has been computed through
. Additional interest of one
percent (1%) must be added for each month or fraction of a month on taxes remaining unpaid.
I promise to pay the full amount due in
installments. As evidence of good faith, the first payment in the amount
of $
is attached.
Each scheduled payment is to be made on or before
Amount of Payment
FINAL PAYMENT TO BE MADE NOT LATER THAN
I further understand that the department will file a lien on any amounts not covered by this agreement that are not
presently in lien.
I agree to make payments as set forth above; extend the period in which the department may collect the above-specified
amount due beyond the time limit provided by Arizona Revised Statutes § 23-743.B if any of the amount remains unpaid
when that time limit is reached; and submit future quarterly reports together with full payment of related amounts due on or
before the due dates.
I understand that if the above conditions are not met, the agreement is cancelled and the balance due and payable may
be collected by levy or execution of judgment.
Dated this
day of
,
Owner, Partner or Corporate Officer’s Signature
PLEASE COMPLETE ALL OF THE INFORMATION REQUESTED ON THE REVERSE SIDE AND RETURN THIS
FORM TO THE ABOVE ADDRESS. FAILURE TO MAKE A FULL DISCLOSURE MAY RESULT IN THIS AGREEMENT
BEING DENIED.
DO NOT WRITE IN SPACE BELOW. FOR USE BY UNEMPLOYMENT TAX ONLY
The above installment payment agreement is accepted this
day of
,
Department Representative’s Signature
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with
Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic
Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities,
or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department must make a
reasonable accommodation to allow a person with a disability to take part in a program, service, or activity. Auxiliary aids and services
are available upon request to individuals with disabilities. To request this document in alternative format or for further information about
this policy, Contact the UI Tax Office at 602-771-6606; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available
upon request. • Ayuda gratuita con traducciones relacionadas con los servicios del DES esta disponible a solicitud del cliente.
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