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Form 71-661-22-8-1-000 (Rev. 10/22)
                                                                      Mississippi                                        Print Form
                                                                Installment Agreement
                                                            MUST BE ATTACHED TO FRONT OF RETURN
  DO NOT file this form if you are currently making payments on an installment agreement.  If you are in bankruptcy, see instructions.
  Taxpayer First Name                              Initial  Last Name                       SSN

  Spouse First Name                                Initial  Last Name                       Spouse SSN

  Mailing Address (Number and Street, Including Rural Route)
                                                                                            If this address is new since you filed
  City                                             State    Zip         County Code         your last tax return, check here:

  Phone Number                     Extension       Best Time to Call

  Banking Information                                                     Employer Information

  Name of your bank or other financial institution                                Your employer's name

  Address                                                                         Address

  City, State, Zip Code                                                           City, State, Zip Code

 Payment Information

1   Enter the tax year for which you are making this request                                                   1

2   Enter the total amount you owe (as shown on your return)                                                   2                                             00
                                                                                                                                                      .

 3   Enter the amount of any payment you are making with your tax return (see instructions)                    3                                             00
                                                                                                                                                      .

 4   Enter the amount due each month (interest will continue until you pay in full)                            4                                             00
                                                                                                                                                      .
 Instructions
An installment agreement is available to taxpayers that have a tax liability of at least $75.  In order to qualify for the installment agreement, the return 
must be filed on or before the due date, or any extensions allowed, and this request form must be submitted with the return.  You (and your spouse if a 
joint return) must have filed all required income tax returns and paid all taxes due for the past five years.  You also can not have previously entered 
into an installment agreement during the past five years.

There are two (2) types of installment agreements for taxpayers that have a tax liability:

 (1)   Tax liability of $75 but no more than $3,000 - The installment agreement allows you to pay the amount due in twelve equal installments.

 (2)   Tax liability exceeding $3,000 and an installment agreement with the Internal Revenue Service (IRS) for the same tax year.  The installment
       agreement allows you to pay the amount due within sixty months.  You must attach a copy of the approved installment agreement
       notification from the IRS.

• The agreement may be terminated if any installment payment is not made timely.  It may also be terminated if you do not pay any other tax liability
when the liability is due.
• Interest of 1/2 % per month continues to accrue during the installment agreement period.  You will need to contact our office for the remaining balance
on the account prior to the last payment to ensure the interest is paid correctly.
• If you have a pending bankruptcy case, you may be barred by federal law from participation in an installment agreement.  Please contact our office for
more details.  Additionally, if you file bankruptcy during the installment period, you must notify our Bankruptcy Section immediately at 601-923-7393.
Due to the automatic stay provisions of the U.S. Bankruptcy Code, the installment agreement may be void at the time you file your bankruptcy case.

                                                   Mail To: Department of Revenue, P.O. Box 23050, Jackson, MS 39225-3050