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

If you are filing this form in response to a notice, do not complete lines 7 through 9. Instead, attach the bottom

section of the notice to this form and go to line 10.

Enter the tax year for which you are making this request (for example, 2001) 

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

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3 4 ( )

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9

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5 6 Name of your bank or other financial institution:

Cat. No. 14842Y

(Rev. December 2001)

Form 9465 (Rev. 12-2001)

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 1-800-829-8815.

.

13 If you want to make your payments by electronic funds withdrawal (direct debit), see the instructions and fill in lines 13a, 13b, and 13c.

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

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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 (direct

debit) 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 1-800-829-8815

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

 c Type: Checking Savings

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For Privacy Act and Paperwork Reduction Act Notice, see back of form.

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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.

1. 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

2. 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.

3. 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.

Purpose of Form

A Notice of Federal Tax Lien may be filed to protect the

government’s interest until you pay in full. CAUTION

!

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 may have up to 60 months to pay. But before

requesting an installment agreement, you should consider other less

costly alternatives, such as a bank loan. If you have any questions about

this request, call 1-800-829-1040.

paid any income tax due, and have not entered into an installment

agreement for payment of income tax.

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.

(99)
Form 9465 (Rev. 12-2001) Page 2

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

Florida, Georgia, North Carolina, South Carolina,

West Virginia

Atlanta, GA

39901

New Jersey, New York (New York City and counties of

Nassau, Rockland, Suffolk, and Westchester)

Holtsville, NY

00501

New York (all other counties), Massachusetts, Michigan,

Rhode Island

Andover, MA

05501

Illinois, Iowa, Kansas, Minnesota, Missouri,

Oklahoma, Utah, Wisconsin

Kansas City, MO

64999

Connecticut, Delaware, District of Columbia, Indiana,

Maine, Maryland, New Hampshire, Pennsylvania, Vermont

Philadelphia, PA

19255

Alaska, California, Hawaii, Nevada, Oregon Fresno, CA

93888

Where To File

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.

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, 17 min.; Preparing the form, 26 min.; and

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

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 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 Tax Forms Committee, Western Area

Distribution Center, Rancho Cordova, CA 95743-0001. Do not send the

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

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

you may send the first payment to the Internal Revenue Service Center at

the address shown on this page that applies to you. See the instructions

for line 10 to find out what to write on your payment.

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 to collect the entire

amount you owe.

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 bank account, you will not receive a letter. Your

bank statement is your record of payment. We will also give you a

statement showing the amount you owe at the beginning of the year, all

payments made during the year, and the amount you owe at the end of

the year.

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.

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, “2001 Form 1040”) for which

you are making this request.

Specific Instructions

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. Be sure not to include the check number.

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.

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 as provided by law. We may also give it to cities, states, and the

District of Columbia to carry out their tax laws.

Lines 13a Through 13c

Instead of sending us a check each month, you can pay by electronic

funds withdrawal from your account at a bank or other financial

institution (such as mutual fund, brokerage firm, or credit union). To do

so, fill in lines 13a, 13b, and 13c. 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 first two digits of the routing number must be 01 through

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

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.

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. 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

Alabama, Arkansas, Kentucky, Louisiana,

Mississippi, Tennessee, Virginia

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.

Arizona, Colorado, Idaho, Montana, New

Mexico, Texas, Wyoming

Austin, TX

73301

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

you owe.

Ohio Cincinnati, OH

45999

Nebraska, North Dakota, South Dakota,

Washington Ogden, UT

84201