2106 E mployee Business Expenses

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I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 9465, PAGE 1 of 4
MARGINS: TOP 13mm (1⁄2 "), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (81⁄2 ")
279mm (11")
PERFORATE: (NONE)
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

9465

Form
(Rev. November 2005)

Department of the Treasury
Internal Revenue Service

Action

Date

Signature

O.K. to print
Revised proofs
requested

Installment Agreement Request
OMB No. 1545-0074

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

front of the return. Otherwise, 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.
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.

2

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

3

(

)
Your home phone number

5

4
Best time for us to call

)
Your work phone number

6

Name of your bank or other financial institution:

(

䊳

Ext.

Best time for us to call

Your employer’s name:

Address

Address

City, state, and ZIP code

City, state, and ZIP code

7

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

䊳

8

Enter the tax year for which you are making this request (for example, 2005)

䊳

9

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

10
11
12
13

9

10
Enter the amount of any payment you are making with your tax return (or notice). See instructions
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
11
䊳
Enter the date you want to make your payment each month. Do not enter a date later than the 28th
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.

䊳

a

Routing number

䊳

b

Account number

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.
Your signature

Date

General Instructions
Section references are to the Internal Revenue Code.

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

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

Date

or credit card payment. If you have any questions about this
request, call 1-800-829-1040.
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.
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.
Cat. No. 14842Y

Form

9465

(Rev. 11-2005)

5
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 9465, PAGE 2 of 4
MARGINS: TOP 13mm (1⁄2 "), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (81⁄2 ")
279mm (11")
PERFORATE: (NONE)
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 9465 (Rev. 11-2005)

● During the past 5 tax years, you (and your spouse if filing a
joint 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.
● 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.

CAUTION

A Notice of Federal Tax Lien may be filed to protect
the government’s interests 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.

What Will You Be Charged

Page

actions, such as a Notice of Federal Tax Lien or an IRS levy,
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).
To find out more about the IRS collection process, see
Pub. 594, The IRS Collection Process.

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 live in . . .

THEN use this address . . .

Alabama, Delaware, Florida, Georgia,
North Carolina, Rhode Island, South Carolina,
Virginia

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.
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).

New Jersey, Pennsylvania

How Does the Installment
Agreement Work

Alaska, Arizona, California, Colorado, Hawaii,
Idaho, Montana, Nebraska, Nevada, New
Mexico, Oregon, South Dakota, Utah,
Washington, Wyoming

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.
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. All payments received will be
applied to your account in the best interests of the United
States. 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.
If your refund is applied to your balance, you are still
required to make your regular monthly installment payment.
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.
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

2

District of Columbia, Maine, Maryland,
Massachusetts, New Hampshire, New York,
Vermont

Arkansas, Kansas, Kentucky, Louisiana,
Mississippi, Oklahoma, Tennessee, Texas,
West Virginia

Atlanta, GA
39901
Andover, MA
05501
Philadelphia, PA
19255
Austin, TX
73301
Fresno, CA
93888

Connecticut, Illinois, Indiana, Iowa, Michigan,
Minnesota, Missouri, North Dakota, Ohio,
Wisconsin

Kansas City, MO
64999

American Samoa, nonpermanent residents
of Guam or the Virgin Islands*, Puerto Rico
(or if excluding income under Internal
Revenue Code Section 933), dual-status
aliens, non-resident aliens, and anyone
filing Form 4563.

Philadelphia, PA
19255
USA

All APO and FPO addresses, a foreign
country: U.S. citizens and anyone filing
Form 2555 or 2555-EZ.

Austin, TX
73301
USA

* Permanent residents of Guam and the Virgin Islands cannot use
Form 9465.

Specific Instructions
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 9
Enter the total amount you owe as shown on your tax return
(or notice).
If the total amount you owe is more than $25,000
(including any amounts you owe from prior years),
CAUTION
complete and attach Form 433-F, Collection
Information Statement. You can get Form 433-F by visiting
the IRS website at www.irs.gov.

5
I.R.S. SPECIFICATIONS
TO BE REMOVED BEFORE PRINTING
INSTRUCTIONS TO PRINTERS
FORM 9465, PAGE 3 of 4 (PAGE 4 IS BLANK)
MARGINS: TOP 13mm (1⁄2 "), CENTER SIDES. PRINTS: HEAD TO HEAD
PAPER: WHITE WRITING, SUB. 20.
INK: BLACK
FLAT SIZE: 216mm (81⁄2 ")
279mm (11")
PERFORATE: (NONE)
DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form 9465 (Rev. 11-2005)

The electronic funds withdrawal from your checking
account will not be approved unless you (and your
spouse if a joint return) sign Form 9465.

Sample Check—Lines 13a and 13b

Line 12

ANYPLACE BANK
Anyplace, VA 20000

You can choose the date your monthly payment is due. This
can be on or after the 1st of the month, but no later than the
28th of the month. For example, if your rent or mortgage
payment is due on the 1st 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.
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 above to
find out what to write on your payment.

For

TIP

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.

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.

SA

PAY TO THE
ORDER OF

15-0000/0000

Routing
number

Account
number

(line 13a)

(line 13b)

|:250250025|:202020

TIP

$

.
"’86" 1234

DOLLARS

Do not include
the check number.

䊲

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.

Lines 13a and 13b

1234

JEFFREY MAPLE
SUZANNE MAPLE
123 Pear Lane
Anyplace, VA 20000

E

Line 11

TIP

PL

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, “2005 Form
1040”) for which you are making this 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.

M

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.

3

䊲

Line 10

Page

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

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.
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.
The average time and expenses required to complete and
file this form will vary depending on individual circumstances.
For the estimated averages, see the instructions for your
income tax return.
If you have suggestions for making this form simpler, we
would be happy to hear from you. See the instructions for
your income tax return.