Form 9465 Installment Agreemenet Request

9465

Form
(Rev. December 2018)

Department of the Treasury
Internal Revenue Service

Installment Agreement Request
▶ Go

to www.irs.gov/Form9465 for instructions and the latest information.
▶ If you are filing this form with your tax return, attach it to the front of the return.
▶ See separate instructions.

OMB No. 1545-0074

Tip: If you owe $50,000 or less, you may be able to avoid filing Form 9465 and establish an installment agreement online, even if you
haven’t yet received a tax bill. Go to www.irs.gov/OPA to apply for an Online Payment Agreement.

Part I
This request is for Form(s) (for example, Form 1040 or Form 941) ▶
Enter tax year(s) or period(s) involved (for example, 2016 and 2017, or January 1, 2017 to June 30, 2017)

1a

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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, also complete the spaces below (see instructions).
Foreign province/state/county

Foreign country name

1b If this address is new since you filed your last tax return, check here
2
Name of your business (must no longer be operating)
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Foreign postal code

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Employer identification number (EIN)

4
Your home phone number

5
6

Best time for us to call

Your work phone number

Ext.

Enter the total amount you owe as shown on your tax return(s) (or notice(s)) . . . . . . . .
If you have any additional balances due that aren’t reported on line 5, enter the amount here (even if
the amounts are included in an existing installment agreement) . . . . . . . . . . . .

7
8
9
10

Add lines 5 and 6 and enter the result . . . . . . . . . . . . . . .
Enter the amount of any payment you’re making with this request. See instructions
Amount owed. Subtract line 8 from line 7 and enter the result
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Divide the amount on line 9 by 72 and enter the result . . . . . . . . . .

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Best time for us to call

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10

11a

Enter the amount you can pay each month. Make your payment as large as possible to limit interest
and penalty charges, as these charges will continue to accrue until you pay in full. If you have
an existing installment agreement, this amount should represent your total proposed monthly
payment amount for all your liabilities. If no payment amount is listed on line 11a, a payment will
be determined for you by dividing the balance due on line 9 by 72 months . . . . . . .
11a $
b If the amount on line 11a is less than the amount on line 10 and you’re able to increase your payment
to an amount that is equal to or greater than the amount on line 10, enter your revised monthly payment 11b $
• If you can’t increase your payment on line 11b to more than or equal to the amount shown on line 10, check the box. Also,
complete and attach Form 433-F, Collection Information Statement . . . . . . . . . . . . . . . . . . .
• If the amount on line 11a (or 11b, if applicable) is more than or equal to the amount on line 10 and the amount you owe is
over $25,000 but not more than $50,000, then you don’t have to complete Form 433-F. However, if you don’t complete Form
433-F, then you must complete either line 13 or 14.
• If the amount on line 9 is greater than $50,000, complete and attach Form 433-F.
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Enter the date you want to make your payment each month. Don’t enter a date later than the 28th
If you want to make your payments by direct debit from your checking account, see the instructions and fill in lines 13a and
13
13b. This is the most convenient way to make your payments and it will ensure that they are made on time.
▶ a Routing number
▶ b Account 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.

c

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Low-income taxpayers only. If you’re unable to make electronic payments through a debit instrument by providing your
banking information on lines 13a and 13b, check this box and your user fee will be reimbursed upon completion of your
installment agreement. See instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If you want to make payments by payroll deduction, check this box and attach a completed Form 2159 .

Your signature

Date

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

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

Date

Cat. No. 14842Y

Form 9465 (Rev. 12-2018)

Form 9465 (Rev. 12-2018)

Page

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Part II
Additional information. Complete this part only if all three conditions apply:
1. you defaulted on an installment agreement in the past 12 months,
2. you owe more than $25,000 but not more than $50,000, and
3. the amount on line 11a (or 11b, if applicable) is less than line 10.
Note: If you owe more than $50,000, complete and attach Form 433-F, Collection Information Statement.
15

In which county is your primary residence?

16a

Marital status:
Single. Skip question 16b and go to question 17.
Married. Go to question 16b.

b Do you share household expenses with your spouse?
Yes.
No.
17

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

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18

How many people in your household are 65 or older?

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19

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

20

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

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20 $

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Note: Complete lines 21 and 22 only if you have a spouse and meet certain conditions (see instructions). If you don’t
have a spouse, go to line 23.
21

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

22

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

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22 $

23

How many vehicles do you own? .

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24

How many car payments do you have each month? . . . . . . . . . . . . . . . . . . .

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25a

Do you have health insurance?
Yes. Go to question 25b.
No. Skip question 25b and go to question 26a.
b Are your health insurance premiums deducted from your paycheck?
Yes. Skip question 25c and go to question 26a.
No. Go to question 25c.
c How much are your monthly health insurance premiums? . . . . . . . . . . . . . .
25c $

26a

Do you make court-ordered payments?
Yes. Go to question 26b.
No. Go to question 27.
b Are your court-ordered payments deducted from your paycheck?
Yes. Go to question 27.
No. Go to question 26c.
c How much are your court-ordered payments each month? . . . . . . . . .

27

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

26c $

27 $
Form 9465 (Rev. 12-2018)