KGTax.com - Installment Agreement Form

Installment Agreement

Please fill out this form if you feel you qualify for an Installment Agreement.
The information will be securely sent to one of the CPAs who will contact you.
If you don't wish to use the internet, you may view the form here, print it out and fax the filled out form to 1-435-752-0277

Section 1 - Contact Information

1. Your first name, initial and last name:

Social Security No.:

Spouse first name, initial and last name:

Social Security No.:

Current home address:

Apt. Number:

City:

State:

Zip:

2. If this address is new since you filed your last tax return, click here:

3. Home phone number:

Best time to call:

4. Work phone number:

Best time to call:

E-mail address:

Section 2 - Financial Information

5. Name of your bank or other financial institution:

Bank address:

City:

State:

Zip:

6. Your employer's name:

Employer address:

City:

State:

Zip:

7. Enter the tax return for which you are making this request (for example, Form 1040):

8. Enter the tax year for which you are making this request (for example, 2000):

9. Enter the total amount you owe as shown on your tax return:

10. Enter the amount of any payment you are making with your tax return (or notice):

11. Enter the amount you can pay each month. Make your payments as large as possible to limit interest and penalty charges. The charges will continue until you pay in full:

12. Enter the date you want to make your payment each month. Do not enter a date later than the 28th:

13. If you want your payments by direct debit, fill in lines 13a, 13b, and 13c

(a) Routing number:

(b) Account Number:

CheckingSavings

Additional Comments: