Form (Rev. December 2012) Department of the Treasury Internal Revenue Service

9465

Installment Agreement Request
Information about Form 9465 and its separate instructions is at www.irs.gov/form9465. 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 less than $50,000, you may be able to establish an installment agreement on-line, even if you have not yet received a bill for your taxes. Go to IRS.gov to apply to pay on-line. 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.
This request is for Form(s) (for example, Form 1040 or Form 1040EZ)

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and for tax year(s) (for example, 2011 and 2012)
Last name Last name Your social security number Spouse’s social security number Apt. number

Your first name and initial If a joint return, spouse’s first name and initial

Current address (number and street). If you have a P.O. box and no home delivery, enter your box 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.

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If this address is new since you filed your last tax return, check here 4
Your home phone number Best time for us to call

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Your work phone number

Ext.

Best time for us to call

Name of your bank or other financial institution: Address City, state, and ZIP code

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Your employer’s name: Address City, state, and ZIP code

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Enter the total amount you