Form 1127 Application for Extension of Time for Payment of Tax

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INSTRUCTIONS TO PRINTERS
FORM 1127, PAGE 1 of 4 (PAGE 2 IS BLANK)
MARGINS: TOP 13 mm (1⁄ 2 "), CENTER SIDES.
PRINTS: HEAD to FOOT
PAPER: WHITE WRITING, SUB. 20
INK: BLACK
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1127

Action

Date

O.K. to print
Revised proofs
requested

Application for Extension of Time for Payment of Tax

(Rev. February 2009)
Department of the Treasury
Internal Revenue Service

Signature

OMB No. 1545-2131

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Before you begin: Use the chart on page 4 to see if you should file this form.

Name shown on return (if a joint return, enter spouse’s name and social security number below)

Social Security Number or Employer Identification Number

Spouse’s name

Spouse’s Social Security Number

Address (number, street, and room or suite no.)

City, town, or post office, state, and ZIP code. If you have a foreign address, see the instructions.

Part I

Request for extension

I request an extension from

,

,

(Enter the due date of the return or the deficiency due date)

to

,

, to pay tax of $

.

(Enter the date you request to pay the tax)

This request is for calendar year

Part II

Reason for extension

or fiscal year ending

,

.

Undue hardship. Enter below a detailed explanation outlining how denial of this request will result in an undue hardship. (If
more space is required, please attach a separate sheet.)

Supporting documentation. To support my request, I am attaching (1) a statement of my assets and liabilities at the end of
last month (showing book and market values of assets and whether securities are listed or unlisted), and (2) an itemized list of
my income and expenses for each of the 3 months prior to the due date of the tax.

Signature and Verification
Under penalties of perjury, I declare that I have examined this application, including any accompanying schedules and statements, and to the best of
my knowledge and belief, it is true, correct, and complete; and, if prepared by someone other than the taxpayer, that I am authorized to prepare this
form.
Signature of taxpayer ©

Date ©

©

Date ©

Signature of preparer
©
other than taxpayer

Date ©

Signature of spouse

For Privacy Act and Paperwork Reduction Act Notice, see separate instructions.

Cat. No. 17238O

Form

1127

(Rev. 2-2009)