Form 9465
(Rev. Dec. 1993)

Department of the Treasury —
Installment Agreement Request

> Please attach this completed agreement request to the front of your tax return or
to the notice we sent you, and mail it to the appropriate IRS office shown on the back.

Internal Revenue Service

OMB Approval No.
Tae 1580
Expires 11/30/96

General Information

If you can't pay the amount you owe in full at this time,
please request an installment agreement by completing
this form. Specify the amount of the monthly payment
you propose to make in the block marked "Proposed
monthly payment amount."

We encourage you to make your payments as large
as possible to lower penalty and interest charges.
Under law, these charges continue to increase until
you pay the balance in full.

Make your check or money order payable to the Internal
Revenue Service, and mark the payment with your name,
address, taxpayer identification number, form number

and tax period. If you have any questions about this pro-
cedure, please call our toll-free number 1-800-829-1040.

Within 30 days, we will let you know if your request for
an installment agreement is approved, or if we need
more information. However, if a 1040 series tax return is
filed after March 31, it may take longer than 30 days to

process this request.

Note: If you are currently in bankruptcy, do not use
this form. Use the above toll-free telephone number and
ask for the telephone number of your local IRS District
Office Special Procedures function.

Your first name and intital Last name

Your social security number

Wa joint return, spouse's first name and intital Last name

‘Spouse's social security number

Home address (number and street). If you have a P.O. box without home delivery, show box number only

Employer identification number(for
business use only)

Apt. no.!

City, province or state, and postal zone or ZIP code

Did this address change
since you last filed?

[_|no [] ves

Country, if not the United States (do not
abbreviate)

Most convenient time for

Business telephone number (include area code
us to call you

and extension number, if any)

Most convenient time for

‘Home telephone number (include area code )
us to call you

Tax return or Tax period Total taxes owed on tax [Amount paid with your | Proposed monthly Date each month | am able to

notice number fetum or notice tax retum or notice —_| payment amount make the payment (Must be
the 1st through the 28th day)

Your signature Date

Spouse's signature (Joint returns only) Date

Privacy Act and Paperwork Reduction Act Notice

We ask for the information on this form under authority
of Internal Revenue Code sections 6001, 6011, 6012(a),
6109, and 6159 and their regulations. We use this
information to process your request for an installment
agreement. The principal reason we need your name
and social security number is to secure proper identifi-
cation. We require this information to gain access to the
tax information in our files and properly respond to your
request. If you do not disclose the information, the IRS
may not be able to process your request.

The time needed to complete and file this form will vary

depending on individual circumstances. The estimated
average time is 10 minutes.

If you have comments concerning the accuracy of this
time estimate or suggestions for making this form more
simple, we would be happy to hear from you. You can
write to both the Internal Revenue Service, Attention:
Reports Clearance Officer, T:FP, Washington, DC 20224,
and the Office of Management and Budget, Paper-
work Reduction Project (1545-1350), Washington, DC
20503. DO NOT send this form to either of these
Offices. See the back for correct mailing addresses.

Catalog No. 14842

Form 9465 (Rev. 12/93)


Where to send Form 9465, Installment Agreement Request:

*Use this address:
If you live in: Internal Revenue Service Center

New Jersey, New York (New York City and counties of Holtsville, NY 00501
Nassau, Rockland, Suffolk, and Westchester)

Illinois, lowa, Minnesota, Missouri, Wisconsin Kansas City, MO 64999

Indiana, Kentucky, Michigan, Ohio, West Virginia Cincinnati, OH 45999

Alaska, Arizona, California (counties of Alpine, Amador, Ogden, UT 84201
Butte, Calaveras, Colusa, Contra Costa, Del Norte, El

Dorado, Glenn, Humboldt, Lake, Lassen, Marin, Mendocino,

Modoc, Napa, Nevada, Placer, Plumas, Sacramento, San

Joaquin, Shasta, Sierra, Siskiyou, Solano, Sonoma, Sutter,

Tehama, Trinity, Yolo, and Yuba), Colorado, Idaho,

Montana, Nebraska, Nevada, North Dakota, Oregon, South

Dakota, Utah, Washington, Wyoming

Alabama, Arkansas, Louisiana, Mississippi, North Carolina, Memphis, TN 37501
Tennessee

Puerto Rica (or if excluding income under section 933) Philadelphia, PA 19255

Virgin Islands:
Nonpermanent residents

All A.P.O. and F.P.O. addresses Philadelphia, PA 19255

%*Use the address shown above even if you file an Form 9465 BACK (Rev. 7/93)
electronic tax return to another address.