9465 (FS) Installment Agreement Request

U.S. Individual Income Tax Return

Form 9465(FS)

U.S. Individual Income Tax Return

OMB: 1545-0074

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1545-0074 can be found here:

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Form

9465-FS

(December 2011)
Department of the Treasury
Internal Revenue Service

Installment Agreement Request
▶ If

OMB No. 1545-0074

your balance due is greater than $25,000 but not more than $50,000, complete Parts I and II.
▶ If you are filing this form with your tax return, attach it to the front of the return.
▶ See

separate instructions.

Caution: Do not file this form if you are currently making payments on an installment agreement or can pay your balance in full within
120 days. 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 in the instructions.
Note. If you are filing Form 9465-FS to request an installment agreement for a business tax liability and the business is no longer a
functioning enterprise, complete line 2 in addition to 1a.
This request is for Form(s) (for example, Form 1040 or Form 941) ▶

Part I
1a

and for tax year(s) (for example, 2010 and 2011) ▶

General Information

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

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.

b If this address is new since you filed your last tax return, check here
2

▶

Employer Identification Number

Business name

3
Your phone number

Best time for us to call

Your work phone number

Name of your bank or other financial institution:

Ext.

Best time for us to call

Your employer’s name:

Address

City, state, and ZIP code

Enter the total amount you owe as shown on your tax return(s) (or notice(s)) . . . . . . . .
Note. If the amount on line 7 is greater than $25,000 but not more than $50,000, you must
complete line 11 and Part II on page 2. See instructions.

8
9

Enter the amount of any payment you are making with your tax return(s) (or notice(s)). 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. If a payment amount
is not listed on line 9, one will be determined for you by dividing the balance due by 72 months .

10
11

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 11a and 11b. This is the most convenient way to make your payments and it will ensure that they are made on time.
▶

▶

b Account number

Routing number

I authorize the U.S. Treasury and its designated Financial Agent to initiate a monthly ACH debit (electronic 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 14 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

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

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

Cat. No. 58658E

Date
Form 9465-FS (12-2011)

Page 2
Additional information. Complete this part only if your answer on line 7 is greater than $25,000 but not more
than $50,000.

Form 9465-FS (12-2011)

Part II
12

In which county is your primary residence?

13a

Marital status:
Single. Skip question 13a and go to question 14.
Married. Go to question 13b.

b Do you share household expenses with your spouse?
Yes.
No.
14

How many dependents will you be able to claim on this year's tax return?

How many people in your household are 65 or older?

. 14

. 15

How often are you paid?
Once a week.
Once every two weeks.
Once a month.
Twice a month.

What is your net income per pay period (take home pay)? .

. 17 $

How often is your spouse paid?
Once a week.
Once every two weeks.
Once a month.
Twice a month.

What is your spouse's net income per pay period (take home pay)? .

. 19 $

How many vehicles do you own? .

. 20

How many car payments do you have each month? .

. 21

22a

Do you have health insurance?
Yes. Go to question 22b.
No. Skip question 22b and go to question 23a.

. 22c $

. 23c $

Not including any court-ordered payments for child and dependent support,
how much do you pay for child or dependent care each month? . . . . .

. 24 $

b Are your premiums deducted from your paycheck?
Yes. Skip question 22c and go to question 23a.
No. Go to question 22c.
c
23a

How much are your monthly premiums? .

Do you make court-ordered payments?
Yes. Go to question 23b.
No. Go to question 24.

b Are your court-ordered payments deducted from your paycheck?
Yes. Go to question 24.
No. Go to question 23c.
c
24

How much are your court-ordered payments each month?.

Form 9465-FS (12-2011)

Instructions for Form
9465-FS

Department of the Treasury
Internal Revenue Service

(December 2011)

Installment Agreement Request
Section references are to the Internal Revenue Code unless
otherwise noted.

General Instructions
Purpose of Form
Use Form 9465-FS to request a monthly installment plan if your
liability is greater than $25,000 but not more than $50,000 and you
cannot pay the full amount you owe shown on your tax return (or on
a notice we sent you). Though Form 9465-FS is meant to be used
by taxpayers with liabilities greater than $25,000 but not more than
$50,000, it can be used by all taxpayers to request an installment
agreement. Generally, you can have up to 72 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.
If you use this form you must file it on paper and attach it to the
front of your return; mailing it to the address shown in your tax
return booklet. If you have already filed your return and you are
sending in Form 9465-FS on its own, mail it to the address shown
in these instructions for the type of return filed. However, before
requesting an installment agreement, you should consider other
less costly alternatives, such as getting a bank loan or using
available credit on a credit card. If you have any questions about
this request, call 1-800-829-1040.
Use Form 9465-FS if you are an individual:

• Who owes income tax on Form 1040,
• Who may be responsible for a Trust Fund Recovery Penalty,
• Who was self-employed and owes self-employment or

unemployment taxes and is no longer operating the business,
• Who is personally responsible for a partnership liability and the
partnership is no longer operating, or
• Owner who is personally responsible for taxes in the name of a
limited liability company (LLC) and the LLC is no longer operating.
Do not use Form 9465-FS if:

• You can pay the full amount you owe within 120 days (see Can

you pay in full within 120 days?), or
• You want to request an online payment agreement (see Applying
online for a payment agreement).
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.
• 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.

A Notice of Federal Tax Lien may be filed to protect the
government’s interests until you pay in full.

CAUTION

Can you pay in full within 120 days? If you can pay the full
amount you owe within 120 days, call 1-800-829-1040 to establish
your request to pay in full. If you can do this, you can avoid paying
the fee to set up an installment agreement. Instead of calling, you
can apply online.
Applying online for a payment agreement. If your balance due
is not more than $50,000, you can apply online for a payment
Dec 23, 2011

agreement instead of filing Form 9465-FS. To do that, go to
IRS.gov and click on “More...” under Tools.
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.

How the Installment Agreement Works
We will usually let you know within 30 days after we receive your
request whether it is approved or denied. However, 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. If we approve your request, we will
send you a notice detailing the terms of your agreement and
requesting a fee of $105 ($52 if you make your payments by
electronic funds withdrawal). However, you may qualify to pay a
reduced fee of $43 if your income is below a certain level. The IRS
will let you know whether you qualify for the reduced fee. If the IRS
does not say you qualify for the reduced fee, you can request the
reduced fee using Form 13844, Application For Reduced User Fee
For Installment Agreements.
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). All
payments received will be applied to your account in the best
interests of the United States.
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. 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.
Payment methods. You can make your payments by check,
money order, credit card, or one of the other payment methods
shown next. The fee for each payment method is also shown.
Payment method

Applicable fee

Check, money order, or credit card

$105

Electronic funds withdrawal

$ 52

Payroll deduction installment
agreement

$105

For details on how to pay, see your tax return instructions, visit
IRS.gov, or call 1-800-829-1040.
After we receive each payment, we will send you a notice
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 notice. Your bank statement is your record of
payment. 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.

Cat. No. 58659P

If you do not make your payments on time or do not pay any
balance due on a return you file later, you will be in default on your
agreement and we may take enforcement actions, such as the filing
of a Notice of Federal Tax Lien or an IRS levy action, 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 11a and 11b, later).
Requests to modify or terminate an installment agreement.
After an installment agreement is approved, you may submit a
request to modify or terminate an installment agreement. This
request will not suspend the statute of limitations on collection.
While the IRS considers your request to modify or terminate the
installment agreement, you must comply with the existing
agreement.

For taxpayers filing Form 1040 with Schedule(s) C, E, or F for any tax
year for which this installment agreement is being requested.

An installment agreement may be terminated if you provide

TIP materially incomplete or inaccurate information in response
to an IRS request for a financial update.

For additional information on the IRS collection process, see
Pub. 594, The IRS Collection Process.

Where To File
Attach Form 9465-FS 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-FS by itself with the Internal Revenue Service Center
using the address in the table below that applies to you.
For all taxpayers except those filing Form 1040 with Schedule(s) C, E,
or F for any tax year for which this installment agreement is being
requested.
IF you live in . . .

THEN use this address . . .

Alabama, Florida, Georgia, Kentucky,
Louisiana, Mississippi, North
Carolina, South Carolina, Texas,
Virginia

Department of the Treasury
Internal Revenue Service
P.O. Box 47421
Stop 74
Doraville, GA 30362

Alaska, Arizona, Colorado,
Connecticut, Delaware, District of
Columbia, Hawaii, Idaho, Illinois,
Maine, Maryland, Massachusetts,
Montana, Nevada, New Hampshire,
New Jersey, New Mexico, North
Dakota, Oregon, Rhode Island, South
Dakota, Tennessee, Utah, Vermont,
Washington, Wisconsin, Wyoming

Department of the Treasury
Internal Revenue Service
310 Lowell St.
Stop 830
Andover, MA 01810

Arkansas, California, Indiana, Iowa,
Kansas, Michigan, Minnesota,
Missouri, Nebraska, New York, Ohio,
Oklahoma, Pennsylvania, West
Virginia

Department of the Treasury
Internal Revenue Service
Stop P-4 5000
Kansas City, MO 64999 – 0250

A foreign country, American Samoa,
or Puerto Rico (or are excluding
income under Internal Revenue Code
section 933), or use an APO or FPO
address, or file Form 2555, 2555-EZ,
or 4563, or are a dual-status alien or
nonpermanent resident of Guam or
the Virgin Islands*

IF you live in . . .

THEN use this address . . .

Alabama, Arkansas, Georgia, Illinois,
Indiana, Iowa, Kansas, Kentucky,
Louisiana, Michigan, Minnesota,
Mississippi, Missouri, Nebraska, New
Jersey, North Dakota, Ohio,
Oklahoma, Pennsylvania, South
Dakota, Tennessee, Texas, West
Virginia, Wisconsin

Department of the Treasury
Internal Revenue Service
P.O. Box 69
Stop 811
Memphis, TN 38101 – 0069

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

Department of the Treasury
Internal Revenue Service
P.O. Box 9941
Stop 5500
Ogden, UT 84409

Connecticut, Maine, Massachusetts,
New Hampshire, New York, Rhode
Island, Vermont

Department of the Treasury
Internal Revenue Service
P.O. Box 480
Stop 660
Holtsville, NY 11742 – 0480

Delaware, Florida, Maryland, District
of Columbia, North Carolina, South
Carolina, Virginia

Department of the Treasury
Internal Revenue Service
Stop 4 – N31.142
Philadelphia, PA 19255 – 0030

Department of the Treasury
Internal Revenue Service
3651 South I-H 35, 5501AUSC
Austin, TX 78741

* Permanent residents of Guam or the Virgin Islands cannot use Form
9465-FS.

Specific Instructions
Part I
Line 1a
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 2
If you are requesting an installment agreement for a business tax
liability, enter the business name and employer identification
number on this line.

Department of the Treasury
Internal Revenue Service
3651 South I-H 35, 5501AUSC
Austin, TX 78741

Line 7
Enter the total amount you owe as shown on your tax return(s) (or
notice(s)).
If the total amount you owe is greater than $25,000 but not
more than $50,000, you must complete Part II and agree to
CAUTION a Direct Debit Installment Agreement (DDIA) to qualify for
an IA without completing a financial statement. If you do not agree
to a DDIA, you must complete Form 433-F, Collection Information
Statement, and mail it with this form.

* Permanent residents of Guam or the Virgin Islands cannot use Form
9465-FS.

If the amount you owe is greater than $50,000, you must complete
Form 433-F and mail it with this form. You can download Form
433-F at IRS.gov or order it by calling 1-800-TAX-FORM
(1-800-829-3676).
If the total amount you owe is not more than $50,000

TIP (including any amounts you owe from prior years), you do

not need to file Form 9465-FS; you can request an
installment agreement online. For more information see Applying
online for a payment agreement, earlier.

-2-

The electronic funds withdrawal from your checking account

Line 8

TIP will not be approved unless you (and your spouse if filing a

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.
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/EIN, and daytime phone number.
• The tax year and tax return (for example,“ 2009 Form 1040”) for
which you are making this request.

joint return) sign Form 9465-FS.

Sample Check — Lines 11a and 11b

SAMPLE

Paul Maple
Roberta Maple
123 Pear Lane
Anyplace, VA 20000
PAY TO THE
ORDER OF

Line 9
Enter on line 9 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. If a payment amount
is not shown on line 9, one will be determined for you by dividing
the balance due by 72 months.

ANYPLACE BANK
Anyplace, VA 20000

Routing
number
(line 11a)

Account
number
(line 11b)

1234
¶

15-0000/0000

$
DOLLARS

Do not include
the check number.

For

|:250250025 |

:202020"'86". 1234 §

Line 10
You can choose the day of each month your 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 day 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 earlier that applies to you.
See the instructions for line 8 above for details on what to write on
your payment.

The routing and account numbers may be in different places

TIP on your check.

Part II
Lines 12—24
Complete Part II only if your balance due is greater than $25,000
but not more than $50,000.
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. You are not required to request an installment
agreement. If you do request an installment agreement, you are
required to provide the information requested on this form. Failure
to provide this information may prevent processing your request;
providing false information may subject you to fines or penalties.
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, the District of Columbia, and U.S. commonwealths
and possessions 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.

Lines 11a and 11b
Making your payments by electronic funds withdrawal will

TIP 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 11a and 11b. Check with
your financial institution to make sure that an electronic funds
withdrawal is allowed and to get the correct routing and account
numbers.
If the total amount you owe is greater than $25,000 but not
more than $50,000, you must agree to a Direct Debit
CAUTION Installment Agreement (DDIA) to qualify for an IA without
completing a financial statement. If you do not agree to a DDIA, you
must complete Form 433-F, Collection Information Statement, and
mail it with this form.
Line 11a. 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 number. 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
number on that check. Instead, contact your financial institution for
the correct routing number.
Line 11b. 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 below, the account number is
20202086. Do not include the check number.
Note. We may have filed a notice of federal tax lien against your
property. If so, you may be able to get the notice of lien withdrawn.
To learn more about lien withdrawals and to see if you qualify, visit
IRS.gov and enter ‘‘lien withdrawal’’ in the search box.

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File Type	application/pdf
File Title	Instruction 9465-FS (December 2011)
Subject	Instructions for Form 9465-FS, Installment Agreement Request
Author	W:CAR:MP:FP
File Modified	2012-02-15
File Created	2011-12-23