Form 1127-A Form 1127-A Application for Extension of Time for Payment of Income

Version A, cycle 1

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Form

1127-A

(Rev. December 2011)
Department of the Treasury
Internal Revenue Service

Application for Extension of Time for Payment of
Income Tax for 2011 Due to Undue Hardship

OMB No. 1545-XXXX

Before you begin: Use the chart on page 3 to see if you should file this form.
Your first name and initial

Last name

Your social security number

If a joint return, spouse's first name and initial

Last name

Spouse'social security number

Home address (number and street). If you have a P.O. box, see instructions.

Apt. no.

City, town, or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions)
Foreign country name

Foreign province/county

Foreign postal code

Please fill in the Return Label at the bottom of this page.
Part I
Eligibility Requirements
Single
Head of household
Filing Status
Married filing jointly (even if only one had income)
Qualifying widow(er)
Check only
one box
Married filing separately
1
Adjusted gross income—Enter the amount of your adjusted gross income (AGI) from Form 1040,
line 37 (Form 1040A, line 21, or Form 1040EZ, line 4) . . . . . . . . . . . . . . .
Note. To qualify for this extension, your AGI must be less than $100,000 ($200,000 if married filing
jointly).
2
Amount you owe—Enter the amount you owe from your 2011 Form 1040, line 76 (Form 1040A, line
45, or Form 1040EZ, line 12) . . . . . . . . . . . . . . . . . . . . . . .

1. $

2. $

Note. You must owe less than $50,000 to qualify for this extension.

Part II

Reason for Extension

at least
I request an extension of time to pay my income tax for 2011 because (check one of the following):
I have been unemployed, or my spouse has been unemployed (if filing a joint return), for 30 consecutive days during 2011 or 2012,
prior to April 15, 2012.
I am self-employed and need an extension of time to pay due to a reduction in business income due to the economy.
Terms for Granting the Extension. By submitting this application, I/we have read, understand, and agree to the
following terms and conditions.

Part III

Terms,
Conditions,
and Legal
Agreement

I/we
Failure to
pay the full
amount by
the payment
extension
date

I understand that this request for an extension of time to pay applies only to income taxes owed for 2011.
I understand that if this request for an extension of time to pay is granted, it will only affect the failure to pay penalty.
I understand that even if this extension of time to pay my income tax is granted, I will still owe interest and any other
penalties on the unpaid amount from April 15, 2012, until the tax is paid in full.
my/our
I understand that in order for this extension to be granted, the full amount of the income tax that I owe, plus interest
and any other penalties, must be paid on or before the extension due date of October 15, 2012.
I understand that if full payment of the amount of the tax for which I am requesting this extension, plus interest and
other penalties, is not paid on or before the payment extension date, a failure to pay penalty will be imposed and
calculated from the original payment due date, April 15, 2012.

Signature and Verification
Under penalties of perjury, I declare that I have examined this application, 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 ▶

Signature of spouse

▶

Date ▶

Signature of preparer
other than taxpayer

▶

Date ▶

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

Cat. No. 58934X

Form

1127-A

(Rev. 12-2011)

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Delete

Version A, cycle 1

Page 2
Please fill in the Return Label below. The IRS will complete the Notice to Applicant and return it to you. If you want it sent
to another address or to an agent acting for you, enter the other address and add the agent's name.
Form 1127-A (Rev. 12-2011)

FOR IRS USE ONLY (Do not detach)
Notice to
Applicant

We have approved your application on the condition that you pay your income tax liability, interest, and
penalities (other than the failure to pay penalty) in full on or before the extension date of October 15, 2012.
Note: You will receive a notice and demand for payment that is automatically generated when you file your
return and the amount shown due on the return is assessed. Because your request for an extension of time to
pay will be granted if you meet the eligibility requirements and full payment is received by the extension date,
you may disregard the payment due date on that notice. Please note that even though your request for an
extension will be granted if full payment is received on or before the extension date, you will owe interest and
all penalties, other than the failure to pay penalty, on the unpaid balance from the original due date of your
return (April 15, 2012) until the tax is paid.
We have not approved your application. After considering the information provided, we have determined that
you are not eligible for this extension.
We cannot consider your application because it was postmarked after April 17, 2012.

To Be
Completed
by the IRS

Other

Date

(Please print or type)

Return Label

Signature of authorized IRS official
Taxpayer’s name (and agent’s name, if applicable). If a joint return, also give spouse’s name.
Address (number and street, include suite, room, or apt. no., or P.O. box number)
City or town, province or state, and country (including postal or ZIP code)

Agents:
Always include taxpayer’s name on Return Label.
Form

1127-A

(Rev. 12-2011)

Delete

Version A, cycle 1

Delete
Form 1127-A (Rev. 12-2011)

Page

Section references are to the Internal Revenue Code.

See Who Should File,
General Instructions below, to determine if you
Purpose of Form
are eligible to use this form.
Use Form 1127-A to ask for an extension of time to pay the income
taxes due, or to be shown as due, on your Form 1040, Form 1040A,
or Form 1040EZ for 2011. The granting of this request for an
extension of time to pay will only result in relief from the failure to
pay penalty and only if the tax, interest, and any other penalties are
fully paid by October 15, 2012.

Determination Chart
Use this chart to determine if Form 1127 is the correct form for you
to file.

income

Dele

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Where To File
File Form 1127-A with the IRS at the following address.
Internal Revenue Service
1040 Waverly Avenue, Stop 662-A
P.O. Box 480
Holtsville, NY 11742-0480

Extension Period
The extension of time to pay your income tax liabilities is
conditioned upon your paying the full amount due on or before the
October 15, 2012 extension date. The granting of this request for an
extension of time to pay will only result in relief from the failure to
pay penalty and only if the tax, interest, and any other penalties are
fully paid by October 15, 2012.

IF you . . .

THEN . . .

Payment Due Date

Are seeking an extension of
time to file your income tax
return

File Form 4868, Application for
Automatic Extension of Time To
File U.S. Individual Income Tax
Return, or Form 2350, Application
for Extension of Time To File U.S.
Income Tax Return. Do not file
Form 1127.

Are seeking an extension of
time to pay estate tax

File Form 4768, Application for
Extension of Time To File a
Return and/or Pay U.S. Estate
(and Generation-Skipping
Transfer) Taxes. Do not file
Form 1127.

You must pay the tax before the extension runs out. Do not wait
to receive a bill from the IRS.
their
Interest. You will owe interest on any tax not paid by the due date
of the return (April 15, 2012) regardless of whether an extension of
Dele
time to pay the tax has been obtained. The interest runs until you
pay the tax.
Penalties. If you fail to pay the full amount of your income tax
liability on or before the extension date, penalties for failure to pay
will be imposed as of the original payment due date (April 15, 2012).

Are requesting a monthly
installment payment plan

2011

-A

See Form 9465, Installment
Agreement Request. Do not file
Form 1127.

Are requesting to postpone
payment of the full amount of
tax shown on your return or
any amount determined as a
deficiency

File Form 1127 by the due date of
your return or by the due date for
the amount determined as a
deficiency.

Owe any tax and are not
requesting, or do not qualify
for, either a monthly installment
payment plan or an extension of
time to pay the full amount

Call, write, or visit your local IRS
office to discuss your situation.
For more information, see Pub.
594, The IRS Collection Process.
Do not file Form 1127.

Who Should File
You are eligible for an extension of time to pay your income taxes
for 2011 if you meet the following requirements:
1. Your income tax liability for 2011, as shown or to be shown on
your Form 1040, 1040A, or 1040EZ, is less than $50,000.
2. Your adjusted gross income, as shown or to be shown on your
Form 1040, 1040A, or 1040EZ, is less than—
$100,000, if your filing status is single, married filing
separately, head of household, or qualifying widow(er)
$200,000, if you are filing a joint return.
3. You are experiencing economic hardship and need a six-month
extension of time to pay your income taxes for 2011 because—
You were or your spouse (if filing a joint return) was
unemployed for 30 consecutive days during 2011 or 2012,
prior to April 15, 2012, or
You are self-employed and you suffered a reduction of
business income due to the economy.

When To File
Your Form 1127-A must be postmarked on or before April 17, 2012.

Note. If you are requesting to postpone payment of tax shown on a
return (other than a tax shown on Form 1040, 1040A, or 1040EZ)
or an amount determined as a deficiency, see Form 1127.

Specific Instructions
Name, Address, and Social Security Number
Enter your name, address, and social security number (SSN) or
individual taxpayer identification number (ITIN). If this application is
for the tax shown on a joint return, include both spouses’ names in
the order in which they appear or will appear on your return.
P.O. box. Enter your box number only if your post office does not
deliver to your street address.
Foreign address. If you have a foreign address, enter the city name
on the appropriate line. Do not enter any other information on that
line, but also complete the spaces below that line. Do not
abbreviate the country name. Follow the country's practice for
entering the postal code and the name of the province, county, or
state.

Part I. Eligibility Requirements
Filing Status. Check the box indicating the filing status you are
claiming on your Form 1040, Form 1040A, or Form 1040EZ.
Adjusted Gross Income. Enter your adjusted gross income (AGI)
from Form 1040, line 37; Form 1040A, line 21; or Form 1040EZ,
line 4.
Note. To qualify for this extension, your AGI must be less than
$100,000 ($200,000 if married filing jointly).
Amount you owe. Enter the amount you owe from your 2011
Form 1040, line 76 (Form 1040A, line 45, or Form 1040EZ, line 12).
Note. You must owe less than $50,000 to qualify for this extension.

Part II. Reason for Extension
Check the appropriate box indicating the reason you need an
extension of time to pay your 2011 income tax liability.

Signature and Verification
This form must be signed and dated.
If this application is for the income tax shown on a joint return,
both you and your spouse must sign and date this form. If your
spouse cannot sign, see Pub. 501.

Version A, cycle 1

Delete

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Form 1127-A (Rev. 12-2011)

Notice to Applicant and Return Label
You must complete the Return Label to receive the Notice to
Applicant. We will use it to tell you if your application is approved.
If the post office does not deliver mail to your street address,
enter your P.O. box number instead.

Contacting the IRS
If you have questions regarding your eligibility for an extension of
time to pay, please call our toll-free number at 1-800-829-1040
(hearing impaired customers with access to TTY/TDD equipment
may call 1-800-829-4059).

Ordering Forms and Publications
You can get forms and publications by calling 1-800-TAX-FORM
(1-800-829-3676), or by visiting your local IRS office or our website
at IRS.gov.

Taxpayer Resources

Low Income
Taxpayer Clinics

You may also seek assistance from a professional tax assistant at a
Low Income Taxpayer Clinic, if you qualify. These clinics provide
help to qualified taxpayers at little or no charge. IRS Publication
4134, Low Income Taxpayer Clinic List, provides information on
clinics in your area and is available through the IRS website at
IRS.gov, by phone at 1-800-TAX-FORM (1-800-829-3676), or at
your local IRS office.
Privacy Act and Paperwork Reduction Act Notice. We ask for
the information on this form to carry out the Internal Revenue laws
of the United States. We need this information to ensure
compliance with these laws and to properly grant extensions of
time to pay tax. Applying for an extension of time for the payment
of tax is voluntary. However, providing the requested information is
mandatory if you apply for the extension. Our legal right to ask for
the information requested on this form is based in sections 6001,
6011, 6109, and 6161 and their regulations. If you fail to provide all
or part of the information requested, your application may be
denied. If you provide false or fraudulent information, you may be
subject to penalties.

4

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, section
6103 allows or requires the Internal Revenue Service to disclose
the information to others as described in the Code. For example,
we may disclose this information to the Department of Justice for
enforcement of civil or criminal tax laws; to cities, states, the
District of Columbia, and U.S. commonwealths or possessions to
administer their tax laws; to other countries under a tax treaty; to
federal and state agencies to enforce non-tax criminal laws; or to
federal law enforcement and intelligence agencies to combat
terrorism.
The time needed to complete and file this form will vary
depending on individual circumstances. The estimated burden for
individual taxpayers filing this form is approved under OMB control
number 1545-0074 and is included in the estimates shown in the
instructions for their individual income tax return. The estimated
burden for all other taxpayers who file this form is shown below.
Recordkeeping . . . . . . . . . . . . 3 hr., 6 min.
Learning about the
law or the form . . . . . . . . . . . . . . 55 min.
Preparing and sending
the form to the IRS . . . . . . . . . . . 3 hr., 25 min.
If you have comments concerning the accuracy of these time
estimates or suggestions for making this form simpler, we would
be happy to hear from you. See the instructions for the tax return
for which this form is filed.