Form 9465-FS

(December 2011)

Department of the Treasury 

Internal Revenue Service 

Installment Agreement Request 

▶ If your balance due is greater than $25,000 but not more than $50,000, complete Parts I and II.

▶ If you are filing this form with your tax return, attach it to the front of the return.

▶ See separate instructions.

OMB No. 1545-0074

Caution: Do not file this form if you are currently making payments on an installment agreement or can pay your balance in full within 

120 days. Instead, call 1-800-829-1040. If you are in bankruptcy or we have accepted your offer-in-compromise, see Bankruptcy or 

offer-in-compromise in the instructions.

Note. If you are filing Form 9465-FS to request an installment agreement for a business tax liability and the business is no longer a 

functioning enterprise, complete line 2 in addition to 1a. 

This request is for Form(s) (for example, Form 1040 or Form 941) ▶ and for tax year(s) (for example, 2010 and 2011) ▶

Part I General Information

1 a 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 

Current address (number and street). If you have a P.O. box and no home delivery, enter your box number. Apt. number 

City, town or post office, state, and ZIP code. If a foreign address, enter city, province or state, and country. Follow the country’s practice for entering the postal code. 

b If this address is new since you filed your last tax return, check here . . . . . . . . . . . . . . . . . ▶

2 Business name Employer Identification Number

3 

Your phone number Best time for us to call 

4 

Your work phone number Ext. Best time for us to call 

5 Name of your bank or other financial institution: 

Address 

City, state, and ZIP code 

6 Your employer’s name: 

Address 

City, state, and ZIP code 

7 Enter the total amount you owe as shown on your tax return(s) (or notice(s)) . . . . . . . . 7 

Note. If the amount on line 7 is greater than $25,000 but not more than $50,000, you must

complete line 11 and Part II on page 2. See instructions. 

8 Enter the amount of any payment you are making with your tax return(s) (or notice(s)). See instructions 8 

9 Enter the amount you can pay each month. Make your payments as large as possible to limit 

interest and penalty charges. The charges will continue until you pay in full. If a payment amount 

is not listed on line 9, one will be determined for you by dividing the balance due by 72 months . 9 

10 Enter the date you want to make your payment each month. Do not enter a date later than the 28th ▶

11 If you want to make your payments by electronic funds withdrawal from your checking account, see the instructions and fill in

lines 11a and 11b. This is the most convenient way to make your payments and it will ensure that they are made on time. 

▶ a Routing number 

▶ b Account number 

I authorize the U.S. Treasury and its designated Financial Agent to initiate a monthly ACH debit (electronic withdrawal) entry to the financial 

institution account indicated for payments of my Federal taxes owed, and the financial institution to debit the entry to this account. This 

authorization is to remain in full force and effect until I notify the U.S. Treasury Financial Agent to terminate the authorization. To revoke 

payment, I must contact the U.S. Treasury Financial Agent at 1-800-829-1040 no later than 14 business days prior to the payment (settlement) 

date. I also authorize the financial institutions involved in the processing of the electronic payments of taxes to receive confidential information 

necessary to answer inquiries and resolve issues related to the payments. 

Your signature Date Spouse’s signature. If a joint return, both must sign. Date 

For Privacy Act and Paperwork Reduction Act Notice, see instructions. Cat. No. 58658E Form 9465-FS (12-2011)
Form 9465-FS (12-2011) Page 2 

Part II Additional information. Complete this part only if your answer on line 7 is greater than $25,000 but not more 

than $50,000. 

12 In which county is your primary residence? 

13a Marital status: 

Single. Skip question 13a and go to question 14. 

Married. Go to question 13b. 

b Do you share household expenses with your spouse?

Yes. 

No. 

14 How many dependents will you be able to claim on this year's tax return? . . . . 14

15 How many people in your household are 65 or older? . . . . . . . . . . . 15

16 How often are you paid?

Once a week.

Once every two weeks.

Once a month.

Twice a month.

17 What is your net income per pay period (take home pay)? . . . . . . . . . . 17 $ 

18 How often is your spouse paid?

Once a week.

Once every two weeks.

Once a month.

Twice a month.

19 What is your spouse's net income per pay period (take home pay)? . . . . . . . 19 $ 

20 How many vehicles do you own? . . . . . . . . . . . . . . . . . . 20

21 How many car payments do you have each month? . . . . . . . . . . . . 21

22a Do you have health insurance?

Yes. Go to question 22b. 

No. Skip question 22b and go to question 23a.

b Are your premiums deducted from your paycheck?

Yes. Skip question 22c and go to question 23a.

No. Go to question 22c.

c How much are your monthly premiums? . . . . . . . . . . . . . . . . 22c $ 

23a Do you make court-ordered payments?

Yes. Go to question 23b. 

No. Go to question 24. 

b Are your court-ordered payments deducted from your paycheck?

Yes. Go to question 24.

No. Go to question 23c.

c How much are your court-ordered payments each month?. . . . . . . . . . 23c $ 

24 Not including any court-ordered payments for child and dependent support, 

how much do you pay for child or dependent care each month? . . . . . . . . 24 $ 

Form 9465-FS (12-2011)