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Form GA-9465 (Rev. 6/2009)

Page 4

Specific Instructions

Step 4: Provide your financial institution’s name and

account information and attach a voided check.

Which Parts must I complete?

Please complete all requested information about your financial

Everyone must complete Steps 1, 3, 4, and 5. Complete Step 2 if

institution and account.

Attach a blank check to your installment

you are a business requesting an installment payment plan for a

payment request and mark “VOID” across the front. Do not use the

sales and use tax liability only.

routing number indicated on your deposit slip.

Return

To avoid processing delays:

The routing number can be found on the front of your check. (Note

• Complete all lines for each part that you are required to execute;

that the routing number is different on your checks and deposit

and

• Do not mail this form to the address on your tax return. Instead,

slips; therefore, be sure to use the routing number on your check.)

mail it to the appropriate address provided under “To what address

It is a nine-digit number; the first two digits of which must be 01

do I mail this form?”

through 12 or 21 through 32. On the sample check on this page,

the routing number is 250250025. But if your check is payable

Step 1: Personal Information (include your spouse, if

through a financial institution different from the one at which you

)

applicable

have your checking account, do not use the routing numbers on

Provide all requested information. If you are married, complete the

that check. Instead, contact your financial insitution for the correct

lines regarding your spouse’s name, social security number, and

routing numbers.

work phone number.

The account number can be up to 17 characters (both numbers and

Step 2: Identify your business and the person

letters). Include hyphens but omit spaces and special symbols. Enter

responsible for remitting payments (business only)

the number from left to right and leave any unused boxes blank. On

the sample check on this page, the account number is 20202086. Do

Complete this section if you are a business requesting an

not include the check number.

installment payment plan. Be sure to provide all requested

information, including the name of the person who will be

responsible for remitting the installment plan payments. Please

include all relevant tax identification numbers.

Step 3:Figure your monthly payment amount

Line 3

Tell us whether or not you have filed all tax returns by

writing an “X” in the appropriate box provided. Note: If you have

not filed all tax returns, you must complete and attach those returns

to this form before we can consider your request.

Line 4

Choose the tax type covered by this agreement. Sales

and use tax and income tax cannot be covered by the same

payment plan form. If you want to enter into a payment plan for both

tax types, please use two separate forms.

Line 5

Identify all tax periods (i.e., month, quarter, or year) for

which the liability on Line 8 exists.

For individual income tax

Step 5: Signature authorization for taxpayer, authorized

liabilities, write the tax year covered by the return. If you need

officer, or partner

additional space, write the tax period beside the line provided or list

You (or in the case of a business, the person responsible for

the tax periods on a separate sheet of paper and attach it to this

remitting payments) must sign the statement.

This signature

form.

authorizes the Georgia Department of Revenue to use the

information on this form to make monthly withdrawals from the

Line 6

Choose whether the payment plan will be for either

account listed in Step 4. This authorization remains in force until the

twelve months or longer. Note: If longer than twelve months, you

Department receives written notification to the contrary from you.

must also provide either a completed Form CDLO-14C Statement

of Financial Affairs for Businesses or Form CDLO-14B Statement of

Financial Affairs for Individuals. Both forms are available on the

Department’s website at

For income tax payment plans, all payments are auto-

Line 7

matically debited on the tenth of each month. For sales and use tax

payment plans, please write the date or dates (1st to the 28th day)

of each month that you want to remit your payment.

Line 8

Enter the total amount of your unpaid liability.

Line 9

Enter the amount of your down payment. The down

payment must be equal or greater than 1/3 of your sales or use tax

liability. No down payment is required for an individual income tax

liability.

Line 10

Enter the amount of your requested monthly payment.

Please make the payment as large as possible to reduce

additional interest accural. Interest and penalty will continue

accrue monthly on the unpaid tax amount.

Instructions For Form Ga-9465 - Installment Payment Agreement Request - Georgia Department Of Revenue Page 2

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