OMB No. 1545-1350

Form 9465 Installment Agreement Request

Department of the Treasury

Internal Revenue Service

 If you are filing this form with your tax return, attach it to the

front of the return. Otherwise, see instructions.

1 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

Your 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.

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

Your home phone number

Enter the tax year for which you are making this request (for example, 2004) 

Enter the total amount you owe as shown on your tax return

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

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

2

3 4 ( )

7

8

9

11

12

5 6 Name of your bank or other financial institution:

Cat. No. 14842Y

(Rev. December 2004)

Form 9465 (Rev. 12-2004)

Best time for us to call Ext.

Your employer’s name: 

Address

City, state, and ZIP code

Address

City, state, and ZIP code

Your work phone number

( )

Best time for us to call

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

Caution: Do not file this form if you are currently making payments on an installment agreement. 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 on

page 2.

If you want to make your payments by electronic funds withdrawal from your checking account, see the instructions and fill in lines 13a

and 13b. This is the most convenient way to make your payments and it will ensure that they are made on time.

13

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

General Instructions

11

10

Enter the tax return for which you are making this request (for example, Form 1040) 

I authorize the U.S. Treasury and its designated Financial Agent to initiate a monthly ACH electronic funds 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 7

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.

 a Routing number

 b Account number

9

For Privacy Act and Paperwork Reduction Act Notice, see page 3.

Section references are to the Internal Revenue Code.

Guaranteed installment agreement. Your request for an

installment agreement cannot be turned down if the tax you

owe is not more than $10,000 and all three of the following

apply.

Purpose of Form

Use Form 9465 to request a monthly installment plan if you

cannot pay the full amount you owe shown on your tax

return (or on a notice we sent you). Generally, you can have

up to 60 months to pay. In certain circumstances, you can

have longer to pay or your agreement can be approved for

an amount that is less than the amount of tax you owe. But

before requesting an installment agreement, you should

consider other less costly alternatives, such as a bank loan

If you do not wish to enter into an installment agreement

on Form 9465, the IRS offers alternative payment options.

Some of these options that you may qualify for are:

● 120 day extension to pay, and

● Payroll deduction installment ageement.

For information on these and other methods of payment,

call 1-800-829-1040.

or credit card payment. If you have any questions about this

request, call 1-800-829-1040.
Form 9465 (Rev. 12-2004) Page 2

IF you live in . . . THEN use this address . . .

Alabama, Florida, Georgia, Mississippi,

North Carolina, Rhode Island, South Carolina,

West Virginia

Atlanta, GA

39901

Maine, Massachusetts, New Hampshire,

New York, Vermont

Andover, MA

05501

Connecticut, Delaware, Illinois, Indiana, Iowa,

Kansas, Michigan, Minnesota, Missouri, Nebraska,

North Dakota, South Dakota, Wisconsin

Kansas City, MO

64999

District of Columbia, Maryland,

New Jersey, Pennsylvania

Philadelphia, PA

19255

Alaska, Arizona, California, Hawaii, Idaho,

Montana, Nevada, Oregon, Utah, Virginia,

Washington, Wyoming

Fresno, CA

93888

Where To File

Attach Form 9465 to the front of your return and send it to

the address shown in your tax return booklet. If you have

already filed your return or you are filing this form in

response to a notice, file Form 9465 by itself with the Internal

Revenue Service Center at the address below for the place

where you live. No street address is needed.

If you do not make your payments on time or you have an

outstanding past-due amount in a future year, you will be in

default on your agreement and we may take enforcement

actions, such as a Notice of Federal Tax Lien or an IRS levy,

After we receive each payment, we will send you a letter

showing the remaining amount you owe, and the due date

and amount of your next payment. But if you choose to have

your payments automatically withdrawn from your checking

account, you will not receive a letter. Your bank statement is

your record of payment. You can also make your payments

by credit card. For details on how to pay, see your tax return

instructions or visit www.irs.gov. We will also send you an

annual statement showing the amount you owed at the

beginning of the year, all payments made during the year,

and the amount you owe at the end of the year.

By approving your request, we agree to let you pay the tax

you owe in monthly installments instead of immediately

paying the amount in full. In return, you agree to make your

monthly payments on time. You also agree to meet all your

future tax liabilities. This means that you must have enough

withholding or estimated tax payments so that your tax

liability for future years is paid in full when you timely file

your return. Your request for an installment agreement will be

denied if all required tax returns have not been filed. Any

refund due you in a future year will be applied against the

amount you owe.

You will be charged a $43 fee if your request is approved.

Do not include the fee with this form. After approving your

request, we will bill you for the fee with your first payment.

What Will You Be Charged

You will also be charged interest and may be charged a

late payment penalty on any tax not paid by its due date,

even if your request to pay in installments is granted. Interest

and any applicable penalties will be charged until the balance

is paid in full. To limit interest and penalty charges, file your

return on time and pay as much of the tax as possible with

your return (or notice).

If we approve your request, we will send you a letter. It will

tell you how to pay the fee and make your first installment

payment. We will usually let you know within 30 days after

we receive your request whether it is approved or denied.

But if this request is for tax due on a return you filed after

March 31, it may take us longer than 30 days to reply.

How Does the Installment

Agreement Work

Ohio* Memphis, TN

37501

If you live in American Samoa or Puerto Rico (or exclude income

under section 933); are a nonpermanent resident of Guam or the

Virgin Islands**; have an APO, FPO, or foreign address; are a

dual-status alien; or file Form 2555, 2555-EZ, or 4563, use this

address: Internal Revenue Service Center, Philadelphia, PA 19255.

** Permanent residents of Guam and the Virgin Islands cannot use

Form 9465.

Arkansas, Colorado, Kentucky, Louisiana,

New Mexico, Oklahoma, Tennessee,

Texas

Austin, TX

73301

● The IRS determines that you cannot pay the tax owed in

full when it is due and you give the IRS any information

needed to make that determination.

● You agree to pay the full amount you owe within 3 years

and to comply with the tax laws while the agreement is in

effect.

A Notice of Federal Tax Lien may be filed to protect

the government’s interest until you pay in full.

Bankruptcy or offer-in-compromise. If you are in

bankruptcy or we have accepted your offer-in-compromise,

do not file this form. Instead, call 1-800-829-1040 to get the

number of your local IRS Insolvency function for bankruptcy

or Technical Support function for offer-in-compromise.

● During the past 5 tax years, you (and your spouse if you

are making a request for a joint tax return) have timely filed

all income tax returns and paid any income tax due, and

have not entered into an installment agreement for payment

of income tax.

to collect the entire amount you owe. To ensure that your

payments are made timely, you should consider making them

by electronic funds withdrawal (see the instructions for lines

13a and 13b).

Line 1

If you are making this request for a joint tax return, show the

names and social security numbers (SSNs) in the same order

as on your tax return.

If you are filing this form by itself, such as in response to a

notice, attach a check or money order payable to the “United

States Treasury.” Do not send cash. Be sure to include:

● Your name, address, SSN, and daytime phone number.

● The tax year and tax return (for example, “2004 Form

1040”) for which you are making this request.

Specific Instructions

Line 10

Even if you cannot pay the full amount you owe now, you

should pay as much as possible to limit penalty and interest

charges. If you are filing this form with your tax return, make

the payment with your return. For details on how to pay, see

your tax return instructions.

CAUTION

To find out more about the IRS collection process, see

Pub. 594.

* If you live in Ohio and are filing this form after June 30, 2005, use:

Fresno, CA 93888.
Form 9465 (Rev. 12-2004) Page 3

Line 11

You should try to make your payments large enough so that

your balance due will be paid off by the due date of your

next tax return.

Line 12

You can choose the date your monthly payment is due. For

example, if your rent or mortgage payment is due on the first

of the month, you may want to make your installment

payments on the 15th. When we approve your request, we

will tell you the month and date that your first payment is

due.

The time needed to complete and file this form will vary

depending on individual circumstances. The estimated

average time is: Learning about the law or the form, 16

min.; Preparing the form, 25 min.; and Copying,

assembling, and sending the form to the IRS, 20 min.

If you have comments concerning the accuracy of this time

estimate or suggestions for making this form simpler, we

would be happy to hear from you. You can write to the

Internal Revenue Service, Tax Products Coordinating

Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave.

NW, IR-6406, Washington, DC 20224. Do not send the form

to this address. Instead, see Where To File on page 2.

If we have not replied by the date you chose for your first

payment, you can send the first payment to the Internal

Revenue Service Center at the address shown on page 2

that applies to you. See the instructions for line 10 on page 2

to find out what to write on your payment.

Privacy Act and Paperwork Reduction Act Notice. Our

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

6001, 6011, 6012(a), 6109, and 6159 and their regulations.

We will use the information to process your request for an

installment agreement. The reason we need your name and

social security number is to secure proper identification. We

require this information to gain access to the tax information

in our files and properly respond to your request. If you do

not enter the information, we may not be able to process

your request.

Line 13b. The account number can be up to 17 characters

(both numbers and letters). Include hyphens but omit spaces

and special symbols. Enter 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 not include the

check number.

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, we may give this information to the

Department of Justice for civil and criminal litigation, and to

cities, states, and the District of Columbia to carry out their

tax laws. We may also disclose this information to other

countries under a tax treaty, to federal and state agencies to

enforce federal nontax criminal laws, or to federal law

enforcement and intelligence agencies to combat terrorism.

Lines 13a and 13b

To pay by electronic funds withdrawal from your checking

account at a bank or other financial institution (such as

mutual fund, brokerage firm, or credit union), fill in lines 13a

and 13b. Check with your financial institution to make sure

that an electronic funds withdrawal is allowed and to get the

correct routing and account numbers.

Note. We will send you a bill for the first payment and the

fee. All other payments will be electronically withdrawn.

Line 13a. The routing number must be nine digits. The first

two digits of the routing number must be 01 through 12 or

21 through 32. Use a check to verify the routing numbers.

On the sample check on this page, the routing number is

250250025. But if your check is payable through a financial

institution different from the one at which you have your

checking account, do not use the routing numbers on that

check. Instead, contact your financial institution for the

correct routing numbers.

Making your payments by electronic funds withdrawal

will help ensure that your payments are made timely

and that you are not in default of this agreement.

TIP

The electronic funds withdrawal from your checking

account will not be approved unless you (and your

spouse if a joint return) sign Form 9465.

TIP

Do not include

the check number.

1234

SAMPLE

JEFFREY MAPLE

SUZANNE MAPLE

123 Pear Lane

Anyplace, VA 20000

15-0000/0000

PAY TO THE

ORDER OF $

DOLLARS

ANYPLACE BANK

Anyplace, VA 20000

For

|:250250025|:202020"’86". 1234

The routing and account numbers may be in different places on your check.

(line 13a) (line 13b)

Routing

number

Account

number





Sample Check—Lines 13a and 13b

TIP