INSTRUCTIONS TO TAXPAYER. If not already completed by an IRS employee, please fill in the information in the spaces provided on the front of this form for the following items: • Your employer’s name and address • Your name(s) (plus spouse’s name if the amount owed is for a joint return) and current address. • Your social security number or employer identification number. (Use the number that appears on the notice(s) you received.) Also, enter the last four digits of your spouse’s social security number if this is a joint liability. • Your home and work telephone number(s) • The complete name and address of your financial institution(s) • The kind of taxes you owe (form numbers) and the tax periods • The amount you owe as of the date you spoke to IRS • When you are paid • The amount you agreed to have deducted from your pay when you spoke to IRS • The date the deduction is to begin • The amount of any increase or decrease in the deduction amount, if you agreed to this with IRS; otherwise, leave BLANK After you complete, sign (along with your spouse if this is a joint liability), and date this agreement form, give it to your participating employer. If you received the form by mail, please give the employer a copy of the letter that came with it. Your employer should mark the payment frequency on the form and sign it. Then, your employer should return the parts of the form which were requested on your letter or return Part 1 of the form to the address shown in the “For assistance” box on the front of the form. If you need assistance, please call the appropriate telephone number below or write IRS at the address shown on the form. However, if you received this agreement by mail, please call the telephone number on the letter that came with it or write IRS at the address shown on the letter. For assistance, call: 0-000-000-0000 (Business), or 0-000-000-0000 (Individual – Self-Employed/Business Owners), or 0-000-000-0000 (Individuals – Wage Earners)
INSTRUCTIONS TO TAXPAYER. If not already completed by an IRS employee, please fill in the information in the spaces provided on the front of this form for the following items: • Your employer’s name and address • Your name(s) (plus spouse’s name if the amount owed is for a joint return) and current address. • Your social security number or employer identification number. (Use the number that appears on the notice(s) you received.) Also, enter the last four digits of your spouse’s social security number if this is a joint liability. • If you are a low-income taxpayer you would qualify for the waiver of your installment agreement fees if you agreed to make electronic payments through a debit instrument (debit payments) by entering into a direct debit installment agreement. This payroll deduction agreement is not a direct debit installment agreement and you are not making debit payments under this agreement. However, if you indicated in the Debit Payments Self-Identifier section of this agreement that you are unable to make debit payments by entering into a direct debit installment agreement, then your installment agreement fees will be reimbursed upon completion of your agreement. Low-income taxpayers, for installment agreement purposes, are individuals with adjusted gross incomes, as determined for the most recent year for which such information is available, at or below 250% of the criteria established by the poverty guidelines updated annually by the U.S. Department of Health and Human Services. • The kind of taxes you owe (form numbers) and the tax periods • The amount you owe as of the date you spoke to IRS • When you are paid • The amount you agreed to have deducted from your pay when you spoke to IRS • The date the deduction is to begin • The amount of any increase or decrease in the deduction amount, if you agreed to this with IRS; otherwise, leave BLANK After you complete, sign (along with your spouse if this is a joint liability), and date this agreement form, give it to your participating employer. If you received the form by mail, please give the employer a copy of the letter that came with it. Your employer should mark the payment frequency on the form and sign it. Then, your employer should return the parts of the form which were requested on your letter or return Part 1 of the form to the address shown in the “For assistance” box on the front of the form. If you need assistance, please call the appropriate telephone number below or write IRS at the address shown on the...
INSTRUCTIONS TO TAXPAYER. If not already completed by an IRS employee, please fill in the information in the spaces provided on the front of this form for: • Your name (include spouse's name if a joint return) and current address; • Your social security number and/or employer identification number (whichever applies to your tax liability); • Your home and work, cell or business telephone numbers; • The complete name, address and phone number of your employer and your financial institution; • The amount you can pay now as a partial payment; • The amount you can pay each month (or the amount determined by IRS personnel); and • The date you prefer to make this payment (This must be the same day for each month, from the 1st to the 28th). We must receive your payment by this date. If you elect the direct debit option, this is the day you want your payment electronically withdrawn from your financial institution account. Review the terms of this agreement. When you've completed this agreement form, please sign and date it. Then, return Part 1 to IRS at the address on the letter that came with it or the address shown in the “For assistance" box on the front of the form. Terms of this agreement By completing and submitting this agreement, you (the taxpayer) agree to the following terms: • This agreement will remain in effect until your liabilities (including penalties and interest) are paid in full, the statutory period for collection has expired, or the agreement is terminated. • You will make each payment so that we (IRS) receive it by the monthly due date stated on the front of this form. If you cannot make a
