INSTALLMENT AGREEMENT

TAX 6065
TEAM ASSIGNMENT 4
INSTALLMENT AGREEMENT
Application for Installment Payment Agreement general information: Following the filing of a
return without payment in full or following an examination and the exhaustion or waiver of Appeals
Division and the United States Tax Court options, the tax is assessed. If the taxpayer is unable to pay
in full, the taxpayer may request an Installment Payment Agreement (“IPA”) or may file an Offer in
Compromise (“OIC”) to reduce the obligation. In addition, IRS may file a tax lien of record and
propose to levy on taxpayer assets. The taxpayer is entitled to a Collection Due Process hearing
(“CDP”) if any administrative rights were not provided or were denied. This includes after the filing
of a lien, prior to a levy, and collection alternatives, including an IPA and an OIC. The United States
Tax Court has jurisdiction to review adverse results of CDP proceedings. The United States Tax Court
does not have jurisdiction to review self-assessed tax because there is no deficiency in tax.
Assignment:
Archie and Betty Veronica, your clients, have filed their 2020 tax return timely on 4/15/2021. They
had a great year in the stock market in 2019. However, much of that was lost in 2020 when they
had to sell stocks being held on margin at substantial losses due to the market mini-crash. Their
cash position, at the time of filing, was bad. They were forced to file owing $54,000 in taxes for
2020. They cannot possibly pay their taxes today. They are unable to borrow any money. Your firm
routinely charges $5,000 for the preparation of an installment agreement involving the preparation
of a Form 433-A. Your clients understand this and are willing to pay assuming that there are no
better options.
They have substantial assets, but those assets are locked up in investments that cannot be liquidated
easily or quickly. They also maintain an expensive lifestyle. They are not a candidate for an Offer in
Compromise.
They have received several IRS letters requesting payment. They do not know what to do. They have
come to your office so that you can advise them what is the best course of action for them to take. They
have asked that you provide them with alternatives and have asked you several questions. They are
also fee sensitive but will pay whatever it takes if they can. They have asked you the following:
1. “If we can come up with the cash relatively quickly, somehow, can you hold off the
IRS without having to go through the expense of doing an installment agreement.
2. “Assuming we cannot come up with any money at all right now what kind of an installment
agreement can we get? “
3. “What needs to be filed or what needs to be done under each of the preceding scenarios in order
to secure the installment agreement and if we secure an installment agreement what is the
maximum amount of time, we can get to pay off our IRS debt?”
4. Will penalty and interest stop, or rates change if we enter an installment agreement? What are
the current rates of interest and the penalty levels if these continue after the installment
agreement?”
Form
433-A
Collection Information Statement for Wage
Earners and Self-Employed Individuals
(May 2020)
Department of the Treasury
Internal Revenue Service
Wage Earners Complete Sections 1, 2, 3, 4, and 5 including the signature line on page 4. Answer all questions or write N/A if the question is not applicable.
Self-Employed Individuals Complete Sections 1, 3, 4, 5, 6 and 7 and the signature line on page 4. Answer all questions or write N/A if the question is not applicable.
For Additional Information, refer to Publication 1854, “How To Prepare a Collection Information Statement.”
Include attachments if additional space is needed to respond completely to any question.
SSN or ITIN on IRS Account
Name on Internal Revenue Service (IRS) Account
Employer Identification Number EIN
Section 1: Personal Information
1a Full Name of Taxpayer and Spouse (if applicable)
1b Address (Street, City, State, ZIP code) (County of Residence)
1c Home Phone
(
)
1e Business Phone
(
)
1d Cell Phone
(
)
1f Business Cell Phone
(
)
2b Name, Age, and Relationship of persons in household or claimed as a
dependent(s)
2a Marital Status:
Married
Unmarried (Single, Divorced, Widowed)
SSN or ITIN
Date of Birth (mmddyyyy)
Driver’s License Number and State
3a Taxpayer
3b Spouse
Section 2: Employment Information for Wage Earners
If you or your spouse have self-employment income instead of, or in addition to wage income, complete Business Information in Sections 6 and 7.
Taxpayer
Spouse
4a Taxpayer’s Employer Name
5a Spouse’s Employer Name
4b Address (Street, City, State, and ZIP code)
5b Address (Street, City, State, and ZIP code)
4d Does employer allow contact at work
Yes
No
4e How long with this employer 4f Occupation
(years)
(months)
4g Number of withholding allowances 4h Pay Period:
claimed on Form W-4
Weekly
Bi-weekly
Monthly
Other
5d Does employer allow contact at work
Yes
No
5e How long with this employer 5f Occupation
(years)
(months)
5g Number of withholding allowances 5h Pay Period:
claimed on Form W-4
Weekly
Bi-weekly
Monthly
Other
4c Work Telephone Number
(
)
5c Work Telephone Number
(
)
Section 3: Other Financial Information (Attach copies of applicable documentation)
6
7
Are you a party to a lawsuit (If yes, answer the following)
Location of Filing
Represented by
Plaintiff
Defendant
Amount of Suit
Possible Completion Date (mmddyyyy)
Subject of Suit
$
Have you ever filed bankruptcy (If yes, answer the following)
Date Filed (mmddyyyy)
Date Dismissed (mmddyyyy)
Date Discharged (mmddyyyy)
Petition No.
Yes
Docket/Case No.
No
Yes
Location Filed
No
8
In the past 10 years, have you lived outside of the U.S for 6 months or longer (If yes, answer the following)
Yes
No
Dates lived abroad: from (mmddyyyy)
To (mmddyyyy)
9a Are you the beneficiary of a trust, estate, or life insurance policy (If yes, answer the following)
Yes
No
Place where recorded:
EIN:
Anticipated amount to be received When will the amount be received
Name of the trust, estate, or policy
$
9b Are you a trustee, fiduciary, or contributor of a trust
Yes
No
Name of the trust:
EIN:
10
Do you have a safe deposit box (business or personal) (If yes, answer the following)
Yes
No
Value
Location (Name, address and box number(s))
Contents
$
11
In the past 10 years, have you transferred any assets for less than their full value (If yes, answer the following)
Yes
No
Value at Time of Transfer Date Transferred (mmddyyyy)
List Asset(s)
To Whom or Where was it Transferred
$
Catalog Number 20312N
www.irs.gov
Form 433-A (Rev. 5-2020)
Page 2
Form 433-A (Rev. 2-2019)
Section 4: Personal Asset Information for all Individuals (Foreign and Domestic)
12
CASH ON HAND Include cash that is not in a bank
Total Cash on Hand
$
PERSONAL BANK ACCOUNTS Include all checking, online and mobile (e.g., PayPal etc.) accounts, money market accounts, savings accounts,
and stored value cards (e.g., payroll cards, government benefit cards, etc.).
Type of Account
Account Balance
Full Name & Address (Street, City, State, ZIP code) of Bank,
Savings & Loan, Credit Union, or Financial Institution
Account Number
As of
mmddyyyy
13a
$
13b
$
13c Total Cash (Add lines 13a, 13b, and amounts from any attachments)
$
INVESTMENTS Include stocks, bonds, mutual funds, stock options, certificates of deposit, and retirement assets such as IRAs, Keogh, 401(k) plans
and commodities (e.g., gold, silver, copper, etc.). Include all corporations, partnerships, limited liability companies, or other business entities in which
you are an officer, director, owner, member, or otherwise have a financial interest. Include attachment(s) if additional space is needed to respond.
Full Name & Address
(Street, City, State, ZIP code) of Company
Type of Investment
or Financial Interest
Current Value
Loan Balance (if applicable)
As of
mmddyyyy
Equity
Value minus Loan
14a
Phone
$
$
$
14b
Phone
$
$
$
VIRTUAL CURRENCY (CRYPTOCURRENCY) List all virtual currency you own or in which you have a financial interest. (e.g., Bitcoin, Ethereum,
Litecoin, Ripple, etc.) If applicable, attach a statement with each virtual currency’s public key.
Type of Virtual Currency
Name of Virtual Currency Wallet,
Exchange or Digital Currency
Exchange (DCE)
Email Address Used to Set-up
With the Virtual Currency
Exchange or DCE
Virtual Currency
Location(s) of Virtual Currency Amount and Value in
(Mobile Wallet, Online, and/or
US dollars as of
External Hardware storage)
today (e.g., 10 Bitcoins
$64,600.00 USD)
14c
$
14d
$
14e
Total Equity (Add lines 14a through 14d and amounts from any attachments)
$
AVAILABLE CREDIT Include all lines of credit and bank issued credit cards.
Full Name & Address (Street, City, State, ZIP code) of Credit Institution
Credit Limit
Amount Owed
Available Credit
As of
As of
mmddyyyy
mmddyyyy
15a
Acct. No
$
$
$
Acct. No
$
$
$
15b
15c Total Available Credit (Add lines 15a, 15b and amounts from any attachments)
$
16a LIFE INSURANCE Do you own or have any interest in any life insurance policies with cash value (Term Life insurance does not have a cash value)
If yes, complete blocks 16b through 16f for each policy.
Yes
No
16b Name and Address of Insurance
Company(ies):
16c
16d
16e
16f
Policy Number(s)
Owner of Policy
Current Cash Value
Outstanding Loan Balance
$
$
$
$
16g Total Available Cash (Subtract amounts on line 16f from line 16e and include amounts from any attachments)
Catalog Number 20312N
www.irs.gov
$
$
$
Form 433-A (Rev. 5-2020)
Page 3
Form 433-A (Rev. 2-2019)
REAL PROPERTY Include all real property owned or being purchased
Current Fair
Market Value
(FMV)
Purchase Date
(mmddyyyy)
Current Loan
Balance
Amount of
Monthly Payment
Date of Final
Payment
(mmddyyyy)
Equity
FMV Minus Loan
17a Property Description
$
Location (Street, City, State, ZIP code) and County
$
$
$
Lender/Contract Holder Name, Address (Street, City, State, ZIP code), and Phone
Phone
17b Property Description
$
Location (Street, City, State, ZIP code) and County
$
$
$
Lender/Contract Holder Name, Address (Street, City, State, ZIP code), and Phone
Phone
17c Total Equity (Add lines 17a, 17b and amounts from any attachments)
$
PERSONAL VEHICLES LEASED AND PURCHASED Include boats, RVs, motorcycles, all-terrain and off-road vehicles, trailers, etc.
Description (Year, Mileage, Make/Model,
Tag Number, Vehicle Identification Number)
18a Year
Mileage
Purchase/
Lease Date
(mmddyyyy)
Current Fair
Market Value
(FMV)
Current Loan
Balance
Amount of
Monthly Payment
Date of Final
Payment
(mmddyyyy)
Equity
FMV Minus Loan
Make/Model
License/Tag Number
$
$
$
Lender/Lessor Name, Address (Street, City, State, ZIP code), and Phone
$
Vehicle Identification Number
Phone
18b Year
Mileage
Make/Model
License/Tag Number
$
$
$
Lender/Lessor Name, Address (Street, City, State, ZIP code), and Phone
$
Vehicle Identification Number
Phone
18c Total Equity (Add lines 18a, 18b and amounts from any attachments)
$
PERSONAL ASSETS Include all furniture, personal effects, artwork, jewelry, collections (coins, guns, etc.), antiques or other assets. Include
intangible assets such as licenses, domain names, patents, copyrights, mining claims, etc.
Purchase/
Lease Date
(mmddyyyy)
Current Fair
Market Value
(FMV)
Current Loan
Balance
Date of Final
Amount of
Payment
Monthly Payment (mmddyyyy)
Equity
FMV Minus Loan
19a Property Description
$
Location (Street, City, State, ZIP code) and County
$
$
$
Lender/Lessor Name, Address (Street, City, State, ZIP code), and Phone
Phone
19b Property Description
$
Location (Street, City, State, ZIP code) and County
$
$
$
Lender/Lessor Name, Address (Street, City, State, ZIP code), and Phone
Phone
19c Total Equity (Add lines 19a, 19b and amounts from any attachments)
Catalog Number 20312N
www.irs.gov
$
Form 433-A (Rev. 5-2020)
Page 4
Form 433-A (Rev. 2-2019)
If you are self-employed, sections 6 and 7 must be completed before continuing.
Section 5: Monthly Income and Expenses
Monthly Income/Expense Statement (For additional information, refer to Publication 1854.)
Total Income
Total Living Expenses
Expense Items 6
Gross Monthly
Source
Actual Monthly
20 Wages (Taxpayer) 1
$
35 Food, Clothing and Misc. 7
$
$
36 Housing and Utilities 8
$
21 Wages (Spouse) 1
22 Interest – Dividends
$
37 Vehicle Ownership Costs 9
$
23 Net Business Income 2
$
38 Vehicle Operating Costs 10
$
24 Net Rental Income 3
$
39 Public Transportation 11
$
25 Distributions (K-1, IRA, etc.) 4
$
40 Health Insurance
$
26 Pension (Taxpayer)
$
41 Out of Pocket Health Care Costs 12
$
27 Pension (Spouse)
$
42 Court Ordered Payments
$
28 Social Security (Taxpayer)
$
43 Child/Dependent Care
$
29 Social Security (Spouse)
$
44 Life Insurance
$
30 Child Support
$
45 Current year taxes (Income/FICA) 13
$
31 Alimony
$
46 Secured Debts (Attach list)
$
Other Income (Specify below) 5
47 Delinquent State or Local Taxes
$
32
$
48 Other Expenses (Attach list)
$
33
$
49 Total Living Expenses (add lines 35-48)
$
34 Total Income (add lines 20-33)
$
50 Net difference (Line 34 minus 49)
$
IRS USE ONLY
Allowable Expenses
1 Wages, salaries, pensions, and social security: Enter gross monthly wages and/or salaries. Do not deduct tax withholding or allotments taken out of
pay, such as insurance payments, credit union deductions, car payments, etc. To calculate the gross monthly wages and/or salaries:
If paid weekly – multiply weekly gross wages by 4.3. Example: $425.89 x 4.3 = $1,831.33
If paid biweekly (every 2 weeks) – multiply biweekly gross wages by 2.17. Example: $972.45 x 2.17 = $2,110.22
If paid semimonthly (twice each month) – multiply semimonthly gross wages by 2. Example: $856.23 x 2 = $1,712.46
2 Net Income from Business: Enter monthly net business income. This is the amount earned after ordinary and necessary monthly business
expenses are paid. This figure is the amount from page 6, line 89. If the net business income is a loss, enter “0”. Do not enter a negative
number. If this amount is more or less than previous years, attach an explanation.
3 Net Rental Income: Enter monthly net rental income. This is the amount earned after ordinary and necessary monthly rental expenses are
paid. Do not include deductions for depreciation or depletion. If the net rental income is a loss, enter “0.” Do not enter a negative number.
4 Distributions: Enter the total distributions from partnerships and subchapter S corporations reported on Schedule K-1, and from limited
liability companies reported on Form 1040, Schedule C, D or E. Enter total distributions from IRAs if not included under pension income.
5 Other Income: Include agricultural subsidies, unemployment compensation, gambling income, oil credits, rent subsidies, sharing economy income
from providing on-demand work, services or goods (e.g., Uber, Lyft, AirBnB, VRBO) and income through digital platforms like an app or website, etc.
6 Expenses not generally allowed: We generally do not allow tuition for private schools, public or private college expenses, charitable
contributions, voluntary retirement contributions or payments on unsecured debts. However, we may allow the expenses if proven that they are
necessary for the health and welfare of the individual or family or the production of income. See Publication 1854 for exceptions.
7 Food, Clothing and Miscellaneous: Total of food, clothing, housekeeping supplies, and personal care products for one month. The miscellaneous
allowance is for expenses incurred that are not included in any other allowable living expense items. Examples are credit card payments, bank fees
and charges, reading material, and school supplies.
8 Housing and Utilities: For principal residence: Total of rent or mortgage payment. Add the average monthly expenses for the following:
property taxes, homeowner’s or renter’s insurance, maintenance, dues, fees, and utilities. Utilities include gas, electricity, water, fuel, oil,
other fuels, trash collection, telephone, cell phone, cable television and internet services.
9
10
11
12
13
Vehicle Ownership Costs: Total of monthly lease or purchase/loan payments.
Vehicle Operating Costs: Total of maintenance, repairs, insurance, fuel, registrations, licenses, inspections, parking, and tolls for one month.
Public Transportation: Total of monthly fares for mass transit (e.g., bus, train, ferry, taxi, etc.)
Out of Pocket Health Care Costs: Monthly total of medical services, prescription drugs and medical supplies (e.g., eyeglasses, hearing aids, etc.)
Current Year Taxes: Include state and Federal taxes withheld from salary or wages, or paid as estimated taxes.
Certification: Under penalties of perjury, I declare that to the best of my knowledge and belief this statement of assets, liabilities, and other
information is true, correct, and complete.
Taxpayer’s Signature
Spouse’s signature
Date
After we review the completed Form 433-A, you may be asked to provide verification for the assets, encumbrances, income and expenses
reported. Documentation may include previously filed income tax returns, pay statements, self-employment records, bank and investment
statements, loan statements, bills or statements for recurring expenses, etc.
IRS USE ONLY (Notes)
Catalog Number 20312N
www.irs.gov
Form 433-A (Rev. 5-2020)
Page 5
Form 433-A (Rev. 2-2019)
Sections 6 and 7 must be completed only if you are SELF-EMPLOYED.
Section 6: Business Information
52
Is the business a sole proprietorship (filing Schedule C)
Yes, Continue with Sections 6 and 7.
No, Complete Form 433-B.
All other business entities, including limited liability companies, partnerships or corporations, must complete Form 433-B.
Business Name & Address (if different than 1b)
53
Employer Identification Number
56
Business Website (web address)
57
Total Number of Employees
59
Frequency of Tax Deposits
60
Does the business engage in e-Commerce
(Internet sales) If yes, complete lines 61a and 61b
51
54
55
Type of Business
58
Is the business a
Federal Contractor
Yes
Average Gross Monthly Payroll
Yes
No
No
PAYMENT PROCESSOR (e.g., PayPal, Authorize.net, Google Checkout, etc.) Include virtual currency wallet, exchange or digital currency exchange.
Name & Address (Street, City, State, ZIP code). Name & Address (Street, City, State, ZIP code)
Payment Processor Account Number
61a
61b
CREDIT CARDS ACCEPTED BY THE BUSINESS
Credit Card
Issuing Bank Name & Address (Street, City, State, ZIP code)
Merchant Account Number
62a
62b
62c
63
BUSINESS CASH ON HAND Include cash that is not in a bank.
Total Cash on Hand $
BUSINESS BANK ACCOUNTS Include checking accounts, online and mobile (e.g., PayPal) accounts, money market accounts, savings accounts,
and stored value cards (e.g., payroll cards, government benefit cards, etc.). Report Personal Accounts in Section 4.
Type of Account
Account Balance
Full name & Address (Street, City, State, ZIP code)
of Bank,Savings & Loan, Credit Union or Financial Institution.
Account Number
As of
mmddyyyy
64a
$
64b
$
64c Total Cash in Banks (Add lines 64a, 64b and amounts from any attachments)
$
ACCOUNTS/NOTES RECEIVABLE Include e-payment accounts receivable and factoring companies, and any bartering or online auction accounts.
(List all contracts separately, including contracts awarded, but not started.) Include Federal, state and local government grants and contracts.
(e.g., age,
Accounts/Notes Receivable & Address (Street, City, State, ZIP code) Status
factored, other)
Date Due
(mmddyyyy)
Invoice Number or Government
Grant or Contract Number
Amount Due
65a
$
65b
$
65c
$
65d
$
65e
$
65f
Total Outstanding Balance (Add lines 65a through 65e and amounts from any attachments)
Catalog Number 20312N
www.irs.gov
$
Form 433-A (Rev. 5-2020)
Page 6
Form 433-A (Rev. 2-2019)
BUSINESS ASSETS Include all tools, books, machinery, equipment, inventory or other assets used in trade or business. Include a list and show the
value of all intangible assets such as licenses, patents, domain names, copyrights, trademarks, mining claims, etc.
Purchase/
Lease Date
(mmddyyyy)
66a
Current Fair
Market Value
(FMV)
Current Loan
Balance
Date of Final
Amount of
Payment
Monthly Payment (mmddyyyy)
Equity
FMV Minus Loan
Property Description
$
$
$
$
Lender/Lessor/Landlord Name, Address (Street, City, State, ZIP code), and Phone
Location (Street, City, State, ZIP code) and Country
Phone
66b
Property Description
$
$
$
$
Lender/Lessor/Landlord Name, Address (Street, City, State, ZIP code), and Phone
Location (Street, City, State, ZIP code) and Country
Phone
66c Total Equity (Add lines 66a, 66b and amounts from any attachments)
$
Section 7 should be completed only if you are SELF-EMPLOYED
Section 7: Sole Proprietorship Information (lines 67 through 87 should reconcile with business Profit and Loss Statement)
Accounting Method Used:
Cash
Accrual
Use the prior 3, 6, 9 or 12 month period to determine your typical business income and expenses.
Income and Expenses during the period (mmddyyyy)
to (mmddyyyy)
Provide a breakdown below of your average monthly income and expenses, based on the period of time used above.
Total Monthly Business Income
Total Monthly Business Expenses (Use attachments as needed)
Expense Items
Actual Monthly
Source
Gross Monthly
Materials Purchased 1
$
Inventory Purchased 2
$
Gross Wages & Salaries
$
Rent
$
Supplies 3
$
Utilities/Telephone 4
$
$
Vehicle Gasoline/Oil
$
72
$
Repairs & Maintenance
$
73
$
Insurance
$
74
5
$
Current
Taxes
$
75
Other Expenses, including installment payments
76 Total Income (Add lines 67 through 75)
$
(Specify)
$
88 Total Expenses (Add lines 77 through 87) $
89 Net Business Income (Line 76 minus 88) 6 $
Enter the monthly net income amount from line 89 on line 23, section 5. If line 89 is a loss, enter “0” on line 23, section 5.
Self-employed taxpayers must return to page 4 to sign the certification.
1 Materials Purchased: Materials are items directly related to the
5 Current Taxes: Real estate, excise, franchise, occupational,
production of a product or service.
personal property, sales and employer’s portion of employment
taxes.
2 Inventory Purchased: Goods bought for resale.
67
68
69
70
71
Gross Receipts
Gross Rental Income
Interest
Dividends
Cash Receipts not included in lines 67-70
Other Income (Specify below)
77
78
79
80
81
82
83
84
85
86
87
$
$
$
$
$
3 Supplies: Supplies are items used in the business that are
consumed or used up within one year. This could be the cost of
books, office supplies, professional equipment, etc.
4 Utilities/Telephone: Utilities include gas, electricity, water, oil, other
fuels, trash collection, telephone, cell phone and business internet.
6 Net Business Income: Net profit from Form 1040, Schedule C may
be used if duplicated deductions are eliminated (e.g., expenses for
business use of home already included in housing and utility
expenses on page 4). Deductions for depreciation and depletion on
Schedule C are not cash expenses and must be added back to the
net income figure. In addition, interest cannot be deducted if it is
already included in any other installment payments allowed.
IRS USE ONLY (Notes)
Privacy Act: The information requested on this Form is covered under Privacy Acts and Paperwork Reduction Notices which have already been
provided to the taxpayer.
Catalog Number 20312N
www.irs.gov
Form 433-A (Rev. 5-2020)
9465
Form
(Rev. September 2020)
Department of the Treasury
Internal Revenue Service
Installment Agreement Request
▶ Go to www.irs.gov/Form9465 for instructions and the latest information.
OMB No. 1545-0074
▶ If you are filing this form with your tax return, attach it to the front of the return.
▶ See separate instructions.
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. If you establish your installment
agreement using the Online Payment Agreement application, the user fee that you pay will be lower than it would be with Form 9465.
Part I
Installment Agreement Request
This request is for Form(s) (for example, Form 1040 or Form 941) ▶
Enter tax year(s) or period(s) involved (for example, 2018 and 2019, or January 1, 2019, to June 30, 2019) ▶
Last name
1a Your first name and initial
Your social security number
Spouse’s social security number
If a joint return, spouse’s first name and initial Last name
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 country name
Foreign province/state/county
1b If this address is new since you filed your last tax return, check here
Name of your business (must no longer be operating)
2
3
.
.
.
.
.
.
.
Foreign postal code
.
.
.
.
.
.
.
.
.
.
▶
Employer identification number (EIN)
4
Your home phone number
Best time for us to call
Your work phone number
Ext.
Best time for us to call
5
6
Enter the total amount you owe as shown on your tax return(s) (or notice(s)) . . . . . . . .
5
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) . . . . . . . . . . . .
6
7
Add lines 5 and 6 and enter the result . . . . . . . . . . . . . . . . . . . .
7
8
Enter the amount of any payment you’re making with this request. See instructions . . . . .
8
9
Amount owed. Subtract line 8 from line 7 and enter the result
. . . . . . . . . . . .
9
10
Divide the amount on line 9 by 72.0 and enter the result . . . . . . . . . . . . . .
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.
12
12
Enter the date you want to make your payment each month. Don’t enter a date later than the 28th
13
If you want to make your payments by direct debit from your checking account, see the instructions and fill in lines 13a and
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
14
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 . . . . . . .
By signing and submitting this form, I authorize the IRS to contact third parties and to disclose my tax information to third parties in order to process this
request and administer the agreement over its duration. I also agree to the terms of this agreement, as provided in the instructions, if it’s approved by the IRS.
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. 14842Y
Date
Form 9465 (Rev. 9-2020)
Page 2
Form 9465 (Rev. 9-2020)
Part II
Additional Information
Complete this Part only if all three conditions below 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, also complete and attach Form 433-F.
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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17
18
How many people in your household are 65 or older?
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18
19
How often are you paid?
Once a week.
Once every 2 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 2 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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23
24
How many car payments do you have each month? . . . . . . . . . . . . . . . . . . .
24
25a
Do you have health insurance?
Yes. Go to question 25b.
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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
26a
How much are your monthly health insurance premiums? .
Do you make court-ordered payments?
Yes. Go to question 26b.
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25c $
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26c $
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
27
How much are your court-ordered payments each month?
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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? . . . . . . . . . . . . . . . . . . .
27 $
Form 9465 (Rev. 9-2020)