Form 1127-A

Department of the Treasury 

Internal Revenue Service 

Application for Extension of Time for Payment of 

Income Tax for 2011 Due to Undue Hardship

OMB No. 1545-2131

2011

Before you begin: See Who Should File in the instructions.

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

Home address (number and street). If you have a P.O. box, see instructions. Apt. no.

City, town, or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions)

Foreign country name Foreign province/county/state Foreign postal code

Part I Eligibility Requirements

Filing Status 

Check only 

one box

Single Head of household

Married filing jointly (even if only one had income) Qualifying widow(er)

Married filing separately

1 Adjusted gross income—Enter the amount of your adjusted gross income (AGI) from your 2011 

Form 1040, line 37 (Form 1040A, line 21, or Form 1040EZ, line 4) . . . . . . . . . . . 1. $

Note. To qualify for this extension, your AGI must be less than $100,000 ($200,000 if married filing 

jointly).

2 Amount you owe—Enter the amount you owe from your 2011 Form 1040, line 76 (Form 1040A, line

45, or Form 1040EZ, line 12) . . . . . . . . . . . . . . . . . . . . . . . 2. $

Note. You must owe less than $50,000 to qualify for this extension.

Part II Reason for Extension 

I request an extension of time to pay my income tax for 2011 because (check one of the following):

I have been unemployed, or my spouse has been unemployed (if filing a joint return), for at least 30 consecutive days during 2011 

or 2012, prior to April 15, 2012.

I am self-employed and need an extension of time to pay due to a 25% or greater reduction in business income in 2011 (relative to 

2010) due to the economic downturn.

Part III Terms for Granting the Extension. By submitting this application, I have read, understand, and agree to the 

following terms and conditions.

Terms, 

Conditions, 

and Legal 

Agreement

I understand that this request for an extension of time to pay applies only to income tax owed for 2011.

I understand that if this request for an extension of time to pay is granted, it will only affect the failure-to-pay penalty.

I understand that even if this extension of time to pay my income tax is granted, I will still owe interest and any other 

penalties on the unpaid amount from April 15, 2012, until the tax is paid in full.

I understand that in order for this extension to be granted, the full amount of the income tax that I owe, plus interest 

and any other penalties, must be paid on or before the extension due date of October 15, 2012.

Note. The IRS will notify you only if your application is not approved.

Failure to 

pay the full 

amount by 

the payment 

extension 

date

I understand that if full payment of the amount of the tax for which I am requesting this extension, plus interest and 

other penalties, is not paid on or before the payment extension date, a failure-to-pay penalty will be imposed and 

calculated from the original payment due date, April 15, 2012. (See instructions.)

Signature and Verification 

Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it is true, correct, and complete; and, if 

prepared by someone other than the taxpayer, that I am authorized to prepare this form. 

Signature of taxpayer ▶ Date ▶

Signature of spouse ▶ Date ▶

Signature of preparer 

other than taxpayer ▶ Date ▶

For Privacy Act and Paperwork Reduction Act Notice, see instructions. Cat. No. 58934X Form 1127-A (2011) 

I understand that I must file my 2011 income tax return by April 17, 2012 (October 15, 2012, if an extension to file was 

requested by filing Form 4868, Application for Automatic Extension of Time To File U.S. Individual Income Tax Return).
Form 1127-A (2011) Page 2 

FOR IRS USE ONLY 

This application is not approved for the following reason(s).

Signature of authorized IRS official Date 

Form 1127-A (2011) 
Form 1127-A (2011) Page 3 

Section references are to the Internal Revenue Code. 

General Instructions 

Purpose of Form 

Use Form 1127-A to ask for an extension of time to pay the income 

tax due, or to be shown as due, on your Form 1040, Form 1040A, or 

Form 1040EZ for 2011. See Who Should File, next, to determine if 

you are eligible to use this form. The granting of this request for an 

extension of time to pay will only result in relief from the failure-topay penalty and only if the tax, interest, and any other penalties are 

fully paid by October 15, 2012.

▲!

CAUTION

Form 1127-A does not extend the time to file your 2011 

income tax return. To get an extension of time to file, you 

must file Form 4868, Application for Automatic Extension 

of Time To File U.S. Individual Income Tax Return.

Future developments. The IRS has created a page on IRS.gov for 

information about Form 1127-A and its instructions at www.irs.gov/

form1127. Information about future developments affecting Form 

1127-A (such as legislation enacted after we release it) will be 

posted on that page.

Who Should File 

You are eligible for an extension of time to pay your income tax for 

2011 if you meet the following requirements:

1. Your income tax liability for 2011, as shown or to be shown on 

your Form 1040, 1040A, or 1040EZ, is less than $50,000.

2. Your adjusted gross income, as shown or to be shown on your 

Form 1040, 1040A, or 1040EZ, is less than—

a. $100,000, if your filing status is single, married filing 

separately, head of household, or qualifying widow(er), or

b. $200,000, if you are filing a joint return.

3. You are experiencing economic hardship and need a six-month 

extension of time to pay your income tax for 2011 because—

a. You were or your spouse (if filing a joint return) was 

unemployed for at least 30 consecutive days during 2011 or 

2012, prior to April 15, 2012, or

b. You are self-employed and you suffered a 25% or greater 

reduction in business income in 2011 (relative to 2010) due 

to the economic downturn.

Note. If you are requesting to postpone payment of tax shown on a 

return (other than a tax shown on Form 1040, 1040A, or 1040EZ) or 

an amount determined as a deficiency, see Form 1127.

When To File 

Your Form 1127-A must be postmarked on or before April 17, 2012.

Where To File 

Mail Form 1127-A to the address shown below that applies to you. 

Do not attach this form to your return or mail it to the address for 

your tax return.

IF you live in . . . THEN mail Form 1127-A to . . . 

Alabama, Alaska, Arizona, 

Arkansas, Colorado, Connecticut, 

Delaware, District of Columbia, 

Hawaii, Idaho, Indiana, Iowa, 

Kansas, Kentucky, Louisiana, 

Maine, Maryland, Massachusetts, 

Minnesota, Mississippi, Missouri, 

Montana, Nebraska, Nevada, New 

Hampshire, New Jersey, New 

Mexico, New York, North Dakota, 

Oklahoma, Oregon, Pennsylvania, 

Rhode Island, South Carolina, 

South Dakota, Tennessee, Utah, 

Vermont, Virginia, Washington, 

West Virginia, Wisconsin, 

Wyoming

Internal Revenue Service 

P.O. Box 480 

Stop 662-X 

Holtsville, NY 11742-0480

California, Florida, Georgia, Illinois, 

Michigan, North Carolina, Ohio, 

Texas

Internal Revenue Service 

P.O. Box 24035 

Stop 81208 

Fresno, CA 93779-4035

A foreign country, U.S. possession 

or territory, or use an APO or FPO 

address.

Internal Revenue Service 

5000 Corporate Dr. 

Holtsville, NY 11742

Extension Period 

The extension of time to pay your income tax liability is conditioned 

upon your paying the full amount of tax, interest, and penalties 

(other than the failure-to-pay penalty) due on or before the October 

15, 2012, extension date. The granting of this request for an 

extension of time to pay will only result in relief from the 

failure-to-pay penalty.

Note. The IRS will notify you only if your application is not 

approved.

Payment Due Date 

You must pay in full all tax, interest, and penalties (other than the 

failure-to-pay penalty) on or before October 15, 2012. Do not wait 

to receive a bill from the IRS. 

Interest. You will owe interest on any tax not paid by April 15, 2012, 

regardless of whether an extension of time to pay the tax has been 

obtained. The interest runs until you pay the tax. 

Penalties. If you fail to pay the full amount of all tax, interest, and 

penalties (other than the failure-to-pay penalty) on or before 

October 15, 2012, the penalty for failure to pay will be imposed as 

of the original payment due date (April 15, 2012).

Specific Instructions 

Name, Address, and Social Security Number 

Enter your name, address, and social security number (SSN) or 

individual taxpayer identification number (ITIN). If this application is 

for the tax shown on a joint return, include both spouses’ names in 

the order in which they appear or will appear on your return.

P.O. box. Enter your box number only if your post office does not 

deliver to your street address. 

Foreign address. If you have a foreign address, enter the city name 

on the appropriate line. Do not enter any other information on that 

line, but also complete the spaces below that line. Do not 

abbreviate the country name. Follow the country's practice for 

entering the postal code and the name of the province, county, or 

state.
Form 1127-A (2011) Page 4 

Part I. Eligibility Requirements

Filing Status. Check the box indicating the filing status you are 

claiming on your 2011 Form 1040, Form 1040A, or Form 1040EZ.

Adjusted Gross Income. Enter your adjusted gross income (AGI) 

from your 2011 Form 1040, line 37 (Form 1040A, line 21, or Form 

1040EZ, line 4).

Note. To qualify for this extension, your AGI must be less than 

$100,000 ($200,000 if married filing jointly).

Amount you owe. Enter the amount you owe from your 2011 Form 

1040, line 76 (Form 1040A, line 45, or Form 1040EZ, line 12). 

Note. You must owe less than $50,000 to qualify for this extension.

Part II. Reason for Extension

Check the appropriate box indicating the reason you need an 

extension of time to pay your 2011 income tax liability.

Part III. Terms for Granting the Extension

Failure to pay the full amount by the payment extension date. 

You will receive a notice and demand for payment that is 

automatically generated when you file your return and the amount 

shown due on the return is assessed. You may disregard the 

payment due date on that notice unless the IRS notifies you that 

your request for an extension of time has not been approved.

Signature and Verification

This form must be signed and dated.

If this application is for the income tax shown on a joint return, 

both you and your spouse must sign and date this form. If your 

spouse cannot sign, see Pub. 501.

Contacting the IRS

If you have questions regarding your eligibility for an extension of 

time to pay, please call our toll-free number at 1-800-829-1040 

(hearing impaired customers with access to TTY/TDD equipment 

may call 1-800-829-4059) or visit our website at 

www.irs.gov/freshstart.

Ordering Forms and Publications

You can get forms and publications by calling 1-800-TAX-FORM 

(1-800-829-3676), or by visiting your local IRS office or our website 

at IRS.gov.

Low Income Taxpayer Clinics

Low Income Taxpayer Clinics (LITCs) are independent from the IRS. 

Some clinics serve individuals whose income is below a certain 

level and who need to resolve a tax problem. These clinics provide 

professional representation before the IRS or in court on audits, 

appeals, tax collection disputes, and other issues for free or for a 

small fee. Some clinics can provide information about taxpayer 

rights and responsibilities in many different languages for individuals 

who speak English as a second language. For more information and 

to find a clinic near you, see the LITC page on 

www.irs.gov/advocate or IRS Publication 4134, Low Income 

Taxpayer Clinic List. This publication is also available by calling 

1-800-829-3676 or at your local IRS office.

Privacy Act and Paperwork Reduction Act Notice. We ask for 

the information on this form to carry out the Internal Revenue laws 

of the United States. We need this information to ensure 

compliance with these laws and to properly grant extensions of 

time to pay tax. Applying for an extension of time for the payment of 

tax is voluntary. However, providing the requested information is 

mandatory if you apply for the extension. Our legal right to ask for 

the information requested on this form is based in sections 6001, 

6011, 6109, and 6161 and their regulations. If you fail to provide all 

or part of the information requested, your application may be 

denied. If you provide false or fraudulent information, you may be 

subject to penalties. 

You are not required to provide the information requested on a 

form that is subject to the Paperwork 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 may become material in the administration of any 

Internal Revenue law. Generally, tax returns and return information 

are confidential, as required by section 6103. However, section 

6103 allows or requires the Internal Revenue Service to disclose 

the information to others as described in the Code. For example, 

we may disclose this information to the Department of Justice for 

enforcement of civil or criminal tax laws; to cities, states, the 

District of Columbia, and U.S. commonwealths or possessions to 

administer their tax laws; to other countries under a tax treaty; to 

federal and state agencies to enforce non-tax criminal laws; or to 

federal law enforcement and intelligence agencies to combat 

terrorism. 

The time needed to complete and file this form will vary 

depending on individual circumstances. The estimated burden for 

taxpayers who file this form is shown below. 

Recordkeeping . . . . . . . . . . . . . . 6 min. 

Learning about the 

law or the form . . . . . . . . . . . . . . 15 min.

Preparing and sending 

the form to the IRS . . . . . . . . . . . . . 58 min.

If you have comments concerning the accuracy of these time 

estimates or suggestions for making this form simpler, we would 

be happy to hear from you. See the instructions for the tax return 

for which this form is filed.