Department of the Treasury — (1993)

Form 9465

(Rev. Dec. 1993)

Department of the Treasury —

Installment Agreement Request

> Please attach this completed agreement request to the front of your tax return or

to the notice we sent you, and mail it to the appropriate IRS office shown on the back.

Internal Revenue Service

OMB Approval No.

1545-1350

Expires 11/30/96

General Information

If you can't pay the amount you owe in full at this time,

please request an installment agreement by completing

this form. Specify the amount of the monthly payment

you propose to make in the block marked "Proposed

monthly payment amount."

We encourage you to make your payments as large

as possible to lower penalty and interest charges.

Under law, these charges continue to increase until

you pay the balance in full.

Make your check or money order payable to the Internal

Revenue Service, and mark the payment with your name,

address, taxpayer identification number, form number

and tax period. If you have any questions about this procedure, please call our toll-free number 1-800- 829-1040.

Within 30 days, we will let you know if your request for

an installment agreement is approved, or if we need

more information. However, if a 1040 series tax return is

filed after March 31, it may take longer than 30 days to

process this request.

Note: If you are currently in bankruptcy, do not use

this form. Use the above toll-free telephone number and

ask for the telephone number of your local IRS District

Office Special Procedures function.

Your first name and intital Last name

Your social security number

if a joint return, spouse's first name and intital Last name

Spouse's social security number

Home address (number and street). If you have a P.O. box without home delivery, show box number only Apt. no.| Employer identification number(for

business use only)

City, province or state, and postal zone or ZIP code

Did this address change

since you last filed?

no | |ves

Country, if not the United States (do not

abbreviate)

Business telephone number (include area code

and extension number, if any) us to call you

Most convenient time for | Home telephone number (include area code )

Most convenient time for

us to call you

Tax return or Tax period Total taxes owed on tax | Amount paid with your | Proposed monthly Date each month | am able to

notice number retum or notice tax retum or notice —_ | payment amount make the payment (Must be

the Ist through the 28th day)

Your signature Date

Spouse's signature (joint returns only) Date

Privacy Act and Paperwork Reduction Act Notice

We ask for the information on this form under authority

of Internal Revenue Code sections 6001, 6011, 6012¢a),

6109, and 6159 and their regulations. We use this

information to process your request for an installment

agreement. The principal reason we need your name

and social security number is to secure proper identification. We require this information to gain access to the

tax information in our files and properly respond to your

request. If you do not disclose the information, the IRS

may not be able to process your request.

The time needed to complete and file this form will vary

depending on individual circumstances. The estimated

average time is 10 minutes.

If you have comments concerning the accuracy of this

time estimate or suggestions for making this form more

simple, we would be happy to hear from you. You can

write to both the Internal Revenue Service, Attention:

Reports Clearance Officer, T:FP, Washington, DC 20224,

and the Office of Management and Budget, Paperwork Reduction Project (1545-1350), Washington, DC

20503. DO NOT send this form to either of these

offices. See the back for correct mailing addresses.

Catalog No. 14842Y

Form 9465 (Rev. 12/93)

Where to send Form 9465, Installment Agreement Request:

. *Use this address:

If you live in: Internal Revenue Service Center

bn Annan:

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New Jersey, New York (New York City and counties of Holtsville, NY 00501

Nassau, Rockland, Suffolk, and Westchester)

Illinois, lowa, Minnesota, Missouri, Wisconsin Kansas City, MO 64999

Indiana, Kentucky, Michigan, Ohio, West Virginia Cincinnati, OH 45999

Alaska, Arizona, California (counties of Alpine, Amador, Ogden, UT 84201

Butte, Calaveras, Colusa, Contra Costa, Del Norte, El

Dorado, Glenn, Humboldt, Lake, Lassen, Marin, Mendocino,

Modoc, Napa, Nevada, Placer, Plumas, Sacramento, San

Joaquin, Shasta, Sierra, Siskiyou, Solano, Sonoma, Sutter,

Tehama, Trinity, Yolo, and Yuba), Colorado, Idaho,

Montana, Nebraska, Nevada, North Dakota, Oregon, South

Dakota, Utah, Washington, Wyoming

Alabama, Arkansas, Louisiana, Mississippi, North Carolina, Memphis, TN 37501

Tennessee

Puerto Rica (or if excluding income under secti

on 933)

Virgin Islands:

Nonpermanent residents

All A.P.O. and F.P.O. addresses Philadelphia, PA 19255

*Use the address shown above even if you file an Form 9465 BACK (Rev. 7/93)

electronic tax return to another address.