Form 1127 APPLICATION FOR EXTENSION OF TIME FOR PAYMENT OF TAX
(Rev. May 1986)

Department of the Treasury (Please read conditions on back before completing this form)

District Director of Internal Revenue at ee a — —
(Enter City and State where IRS Office is located)

, 19, to _ 19 .

I request an extension of time from —__. ~
(Enter Due Date of Return)

in which to pay tax of $______________ for the year ended — , 19 5

This extension is necessary because (If more space is needed, please attach a separate sheet):

T am unable to borrow money to pay the tax because: —_. _ — —

As evidence of the need for the extension, I am attaching: (1) a statement of assets and liabilities as of the last day
of the preceding month (showing book and market values of assets and whether any securities are listed or unlisted);
and (2) an itemized list of receipts and disbursements for the 3 months before the date the tax is due.

I propose to secure the liability covered by this extension as follows:

Under penalties of perjury, I declare that I have examined this application, including any accompanying schedules
and statements, and to the best of my knowledge and belief it is true, correct, and complete.

(SIGNATURE OF APPLICANT) (DATE)

~~ (ADDRESS OF APPLICANT) (EMPLOYER IDENTIFICATION OR
SOCIAL SECURITY NUMBER)

The District Director will let you know whether the extension is granted or denied and will give you the form
of bond, if necessary. However, he or she cannot consider an application if it is filed after the due date of
the return. A list of approved surety companies will be sent to you upon request.

(The following will be filled in by the IRS.)

This application is (2 approved for the following reasons:
(9 disapproved

Interest. C:C«C@ ttle Of assessment SS SsTdeentifying no.

Penalty ee — oe
(SIGNATURE) (DATE)

(over) Form 1127 (Rev. 5-86)



CONDITIONS UNDER WHICH EXTENSIONS OF TIME FOR PAYMENTS MAY BE GRANTED
UNDER SECTION 6161 OF THE INTERNAL REVENUE CODE

The District Director may grant an extension of time for payment of your tax if you can show that it will
cause you undue hardship to pay it on the date it is due. To receive consideration, your application must be
filed with the District Director on or before the date prescribed for payment of the tax.

1, Undue hardship.—This means more than mere inconvenience. You must show that you will have substantial
financial loss if you pay your tax on the date it is due, (Such a loss could be caused by having to sell property
at a sacrifice price.) You must show that you do not have enough cash, above necessary working capital, to
pay the tax. In determining cash available, include anything you can convert into cash, and use current market
prices. Also show that you are unable to borrow money to pay the tax, except under terms that will cause you
severe loss and hardship.

2. Limitations.—As a general rule, an extension of time to pay any part of income or gift tax shown on a return is lim-
ited to 6 months from the date fixed for payment. An extension may be granted for more than 6 months if you are abroad.

An extension of time to pay any part of a deficiency (an amount determined to be due after an examina-
tion of your return) in income or gift tax is limited to 18 months from the date fixed for payment and, in
exceptional cases, for an additional period of not more than 12 months.

No extension is granted to pay a deficiency that is due to negligence, intentional disregard of rules and regulations,
or fraud with intent to evade tax.

3. Interest.—Interest is charged at the annual rate established under Code section 6621(a) (subject to adjust-
ments as provided in Code section 6621(b)).

4. Security.—Sccurity satisfactory to the District Director is required as a condition for granting an extension. This is
to assure that the risk of loss to the Government will be no greater at the end of the extension period than it was at the
beginning. The determination of the kind of security, such as bond, filing of notice of lien, mortgage, pledge, deed of trust
of specific property or general assets, personal surety, or other, will depend on the circumstances in each case. Ordinarily,
when you receive notice of approval of your application, you should deposit with the District Director any collateral that
was agreed upon for security purposes. No collateral is required if you have no assets.

5. Due date of payment for which extension is granted.—On or before the end of the extension period, pay the tax for
which the extension is granted (without notice and demand from the District Director).

6. Filing requirements.—If you need an extension of time to pay tax, submit an application with supporting
documents on or before the date the tax is due, File the application with the District Director where you
maintain your legal residence or principal place of business. If, however, the tax is to be paid to the Director,
Foreign Operations District, file the application with that office. If you need an extension to pay estate tax,
file Form 4768, Application for Extension of Time to File U.S. Estate Tax Return and/or Pay Estate Tax.

Form 1127 (Rev. 5-86)
4*U.S.GP0:1988-202-004/72433