Instructions For Form 9465 - Installment Agreement Request (Page 5 of 5) in pdf

The direct debit from your checking account won’t

Privacy Act and Paperwork Reduction Act Notice.

be approved unless you (and your spouse if filing

TIP

Our legal right to ask for the information on this form is

a joint return) sign Form 9465.

sections 6001, 6011, 6012(a), 6109, and 6159 and their

regulations. We will use the information to process your

Sample Check—Lines 13a and 13b

request for an installment agreement. The reason we

Paul Maple

1234

need your name and social security number is to secure

SAMPLE

Roberta Maple

proper identification. We require this information to gain

123 Pear Lane

15-0000/0000

Anyplace, VA 20000

access to the tax information in our files and properly

respond to your request. You aren’t required to request an

PAY TO THE

ORDER OF

Routing

Account

installment agreement. If you do request an installment

number

DOLLARS

agreement, you’re required to provide the information

(line 13a)

(line 13b)

ANYPLACE BANK

Don’t include

requested on this form. Failure to provide this information

Anyplace, VA 20000

the check number.

may prevent processing your request; providing false

For

information may subject you to fines or penalties.

:250250025

:202020"'86".

1234

You aren’t required to provide the information

The routing and account numbers may be in

requested on a form that is subject to the Paperwork

different places on your check.

TIP

Reduction Act unless the form displays a valid OMB

control number. Books or records relating to a form or its

instructions must be retained as long as their contents

Line 14

may become material in the administration of any Internal

If you want to make your payments by payroll deduction,

Revenue law. Generally, tax returns and return

check the box on line 14 and attach a completed and

information are confidential, as required by section 6103.

signed Form 2159. Ask your employer to complete and

However, we may give this information to the Department

sign the employer’s portion of Form 2159.

of Justice for civil and criminal litigation, and to cities,

states, the District of Columbia, and U.S. commonwealths

If you choose to make your payments by payroll

and possessions to carry out their tax laws. We may also

deduction, you won’t be able to file Form 9465

disclose this information to other countries under a tax

electronically.

CAUTION

treaty, to federal and state agencies to enforce federal

Part II

nontax criminal laws, or to federal law enforcement and

intelligence agencies to combat terrorism.

If you have defaulted on an installment agreement within

the last 12 months, and the amount you owe is greater

The average time and expenses required to complete

than $25,000 but not more than $50,000, complete Part II

and file this form will vary depending on individual

on page 2 of Form 9465.

circumstances. For the estimated averages, see the

instructions for your income tax return.

Lines 21 and 22

If you have suggestions for making this form simpler,

Complete lines 21 and 22 relating to income earned by

we would be happy to hear from you. See the instructions

your spouse if you are married and meet either of the

for your income tax return.

following conditions.

You live with and share household expenses with your

spouse. Even if only one spouse is liable for the taxes

owed, total household income and expenses are relevant

to determining the liable spouse’s ability to pay the taxes

owed.

You live in a community property state. In a community

property state, the income of a non-liable spouse may be

factored into the other spouse’s ability to pay the taxes

owed.

You should complete lines 21 and 22 whether your filing

status is married filing jointly or married filing separately.

-5-

Instructions For Form 9465 - Installment Agreement Request Page 5

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