Form 9465

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.

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)

1a Your name

First NameLast Name

Your social security number

Spouse's name (if joint return)

First NameLast Name

Spouse's social security number

Current address

Street Address

Street Address Line 2

City

Foreign address details (if applicable)

Street Address

Street Address Line 2

State / Province

Postal / Zip CodeCountry

2 Name of your business (must no longer be operating)

Employer identification number (EIN)

3 Your home phone number

Format: (000) 000-0000.

4 Your work phone number

Area CodePhone Number

5 Enter the total amount you owe as shown on your tax return(s) (or notice(s))

6 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 Add lines 5 and 6 and enter the result

8 Enter the amount of any payment you're making with this request. See instructions

9 Amount owed. Subtract line 8 from line 7 and enter the result

10 Divide the amount on line 9 by 72.0 and enter the result

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

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

• 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 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.

13a Routing number

13b 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.

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

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

Date

Form 9465 (Rev. September 2020)Department of the Treasury - Internal Revenue ServiceInstallment Agreement Request

Part I: Installment Agreement Request

Part II Additional Information