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Page 1 of 3                                                                Instructions for Form 9465-FS                                                                                                                                                                                                                                                                         13:48 - 23-DEC-2011

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

                                                                                                                                                                                                                                                                                                                                                                                    Department of the Treasury
Instructions for Form                                                                                                                                                                                                                                                                                                                                                               Internal Revenue Service

9465-FS

(December 2011)
Installment Agreement Request

Section references are to the Internal Revenue Code unless                                                                                                                                                                           agreement instead of filing Form 9465-FS. To do that, go to
otherwise noted.                                                                                                                                                                                                                     IRS.gov and click on “More...” under Tools.
                                                                                                                                                                                                                                     Bankruptcy or offer-in-compromise.                                                                                                                                               If you are in bankruptcy or
General Instructions                                                                                                                                                                                                                 weInstead,havecallaccepted1-800-829-1040your offer-in-compromise,to get the numberdoofnotyourfilelocalthis form.IRS
                                                                                                                                                                                                                                     Insolvency function for bankruptcy or Technical Support function for
Purpose of Form                                                                                                                                                                                                                      offer-in-compromise.
Use Form 9465-FS to request a monthly installment plan if your
liability is greater than $25,000 but not more than $50,000 and you                                                                                                                                                                  How the Installment Agreement Works
cannot pay the full amount you owe shown on your tax return (or on                                                                                                                                                                   We will usually let you know within 30 days after we receive your
a notice we sent you). Though Form 9465-FS is meant to be used                                                                                                                                                                       request whether it is approved or denied. However, if this request is
by taxpayers with liabilities greater than $25,000 but not more than                                                                                                                                                                 for tax due on a return you filed after March 31, it may take us
$50,000, it can be used by all taxpayers to request an installment                                                                                                                                                                   longer than 30 days to reply. If we approve your request, we will
agreement. Generally, you can have up to 72 months to pay. In                                                                                                                                                                        send you a notice detailing the terms of your agreement and
certain circumstances, you can have longer to pay or your                                                                                                                                                                            requesting a fee of $105 ($52 if you make your payments by
agreement can be approved for an amount that is less than the                                                                                                                                                                        electronic funds withdrawal). However, you may qualify to pay a
amount of tax you owe.                                                                                                                                                                                                               reduced fee of $43 if your income is below a certain level. The IRS
  If you use this form you must file it on paper and attach it to the                                                                                                                                                                will let you know whether you qualify for the reduced fee. If the IRS
front of your return; mailing it to the address shown in your tax                                                                                                                                                                    does not say you qualify for the reduced fee, you can request the
return booklet. If you have already filed your return and you are                                                                                                                                                                    reduced fee using Form 13844, Application For Reduced User Fee
sending in Form 9465-FS on its own, mail it to the address shown                                                                                                                                                                     For Installment Agreements.
in these instructions for the type of return filed. However, before
requesting an installment agreement, you should consider other                                                                                                                                                                       You will also be charged interest and may be charged a late
less costly alternatives, such as getting a bank loan or using                                                                                                                                                                       payment penalty on any tax not paid by its due date, even if your
available credit on a credit card. If you have any questions about                                                                                                                                                                   request to pay in installments is granted. Interest and any
this request, call 1-800-829-1040.                                                                                                                                                                                                   applicable penalties will be charged until the balance is paid in full.
                                                                                                                                                                                                                                     To limit interest and penalty charges, file your return on time and
  Use Form 9465-FS if you are an individual:                                                                                                                                                                                         pay as much of the tax as possible with your return (or notice). All
• Who owes income tax on Form 1040,                                                                                                                                                                                                  payments received will be applied to your account in the best
• Who may be responsible for a Trust Fund Recovery Penalty,                                                                                                                                                                          interests of the United States.
• Who was self-employed and owes self-employment or
unemployment taxes and is no longer operating the business,                                                                                                                                                                          By approving your request, we agree to let you pay the tax you
• Who is personally responsible for a partnership liability and the                                                                                                                                                                  owe in monthly installments instead of immediately paying the
partnership is no longer operating, or                                                                                                                                                                                               amount in full. In return, you agree to make your monthly payments
• Owner who is personally responsible for taxes in the name of a                                                                                                                                                                     on time. You also agree to meet all your future tax liabilities. This
limited liability company (LLC) and the LLC is no longer operating.                                                                                                                                                                  means that you must have enough withholding or estimated tax
                                                                                                                                                                                                                                     payments so that your tax liability for future years is paid in full
  Do not use Form 9465-FS if:                                                                                                                                                                                                        when you timely file your return. Your request for an installment
• You can pay the full amount you owe within 120 days (see Can                                                                                                                                                                       agreement will be denied if all required tax returns have not been
you pay in full within 120 days?), or                                                                                                                                                                                                filed. Any refund due you in a future year will be applied against the
• You want to request an online payment agreement (see Applying                                                                                                                                                                      amount you owe. If your refund is applied to your balance, you are
online for a payment agreement).                                                                                                                                                                                                     still required to make your regular monthly installment payment.
Guaranteed installment agreement.                                                                                                  Your request for an
installment agreement cannot be turned down if the tax you owe is                                                                                                                                                                    Payment methods.                                                              You can make your payments by check,
not more than $10,000 and all three of the following apply.                                                                                                                                                                          money order, credit card, or one of the other payment methods
• During the past 5 tax years, you (and your spouse if filing a joint                                                                                                                                                                shown next. The fee for each payment method is also shown.
taxreturn)due,haveandtimelyhave notfiledenteredall incomeintotaxan installmentreturns andagreementpaid any incomefor                                                                                                                 Payment method                                                                                                                              Applicable fee
payment of income tax.                                                                                                                                                                                                               Check, money order, or credit card                                                                                                          $105
• The IRS determines that you cannot pay the tax owed in full
when it is due and you give the IRS any information needed to                                                                                                                                                                        Electronic funds withdrawal                                                                                                                 $ 52
make that determination.                                                                                                                                                                                                             Payroll deduction installment                                                                                                               $105
• You agree to pay the full amount you owe within 3 years and to                                                                                                                                                                     agreement
comply with the tax laws while the agreement is in effect.

             A Notice of Federal Tax Lien may be filed to protect the                                                                                                                                                                For details on how to pay, see your tax return instructions, visit
CAUTION!     government’s interests until you pay in full.                                                                                                                                                                           IRS.gov, or call 1-800-829-1040.

canCanyourtheamountfeeapplyyourequesttoyoupaysetonline.owetoupinpayfullanwithinininstallmentwithinfull.120If120days,youagreement.days?cancalldo1-800-829-1040this,If youInsteadyoucancanpayofavoidcalling,totheestablishfullpayingyouamountshowingwillpaymentspayment.Afternot receiveofwetheWeautomaticallyyourreceiveremainingwillanextnotice.alsoeachpayment.sendamountwithdrawnYourpayment,youbankButyouaniffromannualwestatementowe,youwillyourchooseandsendstatementcheckingtheisyouyourtoduehavearecordshowingdatenoticeaccount,yourandoftheyou
Applying online for a payment agreement.                                                                                                                  If your balance due                                                        amount you owed at the beginning of the year, all payments made
is not more than $50,000, you can apply online for a payment                                                                                                                                                                         during the year, and the amount you owe at the end of the year.
Dec 23, 2011                                                                                                                                                                                                   Cat. No. 58659P



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Page 2 of 3                                                                                            Instructions for Form 9465-FS                                                                                                                                                                                                                                                                                                                                                                                                                                             13:48 - 23-DEC-2011

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

   If you do not make your payments on time or do not pay any                                                                                                                                                                                                                                                                                                                         For taxpayers filing Form 1040 with Schedule(s) C, E, or F for any tax
balance due on a return you file later, you will be in default on your                                                                                                                                                                                                                                                                                                                year for which this installment agreement is being requested.
agreementof a Notice andof Federalwe mayTaxtakeLienenforcementor an IRS levyactions,action,suchto collectas the filingthe                                                                                                                                                                                                                                                             IF you live in . . .                                                                                                                                                                       THEN use this address . . .
entire amount you owe. To ensure that your payments are made                                                                                                                                                                                                                                                                                                                          Alabama, Arkansas, Georgia, Illinois,

WhilewithdrawalAftertimely,requestRequestsrequestantheyouwilltoinstallmentIRSmodifyto(seeshouldnotmodifyconsiderssuspendtheorconsideragreementinstructionsterminateor terminateyourthemakingstatuterequestanisforapproved,installmentanlinesthemoftoinstallmentlimitationsmodify11abyyouelectronicandagreement.ormayon11b,terminateagreement.collection.submitlater).fundsThisthea    Virginia,Dakota,Oklahoma,Mississippi,Jersey,Louisiana,Indiana,NorthTennessee,Iowa,WisconsinMichigan,Pennsylvania,Missouri,Dakota,Kansas,Texas,Minnesota,Nebraska,Ohio,Kentucky,SouthWestNewDepartmentMemphis,Internal RevenueTNof the38101–0069P.O.TreasuryStopServiceBox81169

agreement.installmentTIP Anmateriallyinstallmentagreement,incompleteagreementyou mustor inaccuratecomplymay bewithterminatedinformationthe existingifinyouresponseprovide                                                                                                                                                                                                             Alaska,Hawaii,Washington,New Mexico,Idaho,Arizona,WyomingOregon,Montana,California,Utah,Nevada,Colorado,                                                                                   DepartmentInternalOgden,RevenueofP.O.theStopUTTreasuryBoxService8440999415500
                 to an IRS request for a financial update.

Pub.For594,additionalThe IRSinformationCollectiononProcess.the IRS collection process, see                                                                                                                                                                                                                                                                                            Connecticut,New Hampshire,Maine,NewMassachusetts,York, Rhode                                                                                                                               DepartmentInternal RevenueofP.O.the TreasuryBoxService480
                                                                                                                                                                                                                                                                                                                                                                                      Island, Vermont                                                                                                                                                                                                                    Stop 660
Where To File                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Holtsville, NY 11742–0480

FormAttachyouraddressreturn9465-FSFormshownor9465-FSyoubyinitselfyouraretofilingtaxwiththereturnthisthefrontformInternalbooklet.of yourin responseRevenuereturnIf youandhavetoServiceasendnotice,alreadyitCentertofilefiledthe                                                                                                                                                        Carolina,ofDelaware,Columbia,VirginiaFlorida,NorthMaryland,Carolina, SouthDistrict                                                                                                         Philadelphia,DepartmentInternal RevenueStopPAof19255–0030the4–N31.142TreasuryService
using the address in the table below that applies to you.
                                                                                                                                                                                                                                                                                                                                                                                      A foreign country, American Samoa,
For all taxpayers except those filing Form 1040 with Schedule(s) C, E,                                                                                                                                                                                                                                                                                                                or Puerto Rico (or are excluding
or F for any tax year for which this installment agreement is being                                                                                                                                                                                                                                                                                                                   income under Internal Revenue Code                                                                                                                                                         Department of the Treasury 
requested.                                                                                                                                                                                                                                                                                                                                                                            section 933), or use an APO or FPO                                                                                                                                                         Internal Revenue Service
                                                                                                                                                                                                                                                                                                                                                                                      address, or file Form 2555, 2555-EZ,                                                                                                                                                       3651 South I-H 35, 5501AUSC
IF you live in . . .                                                                                                                                                                                                            THEN use this address . . .                                                                                                                           or 4563, or are a dual-status alien or                                                                                                                                                          Austin, TX 78741

Carolina,Alabama,VirginiaLouisiana,SouthFlorida,Mississippi,Carolina,Georgia,NorthTexas,Kentucky,                                                                                                                               DepartmentInternalDoraville,RevenueP.O.of theBoxGATreasuryStopService303624742174                                                                     *the9465-FS.nonpermanentPermanentVirgin Islands*residentsresidentofofGuamGuamororthe Virgin Islands cannot use Form
Alaska, Arizona, Colorado,
Connecticut, Delaware, District of
Columbia, Hawaii, Idaho, Illinois,                                                                                                                                                                                              Department of the Treasury 
Maine, Maryland, Massachusetts,Montana, Nevada, New Hampshire,                                                                                                                                                                                           Internal Revenue Service310 Lowell St.                                                                                       Specific Instructions
New Jersey, New Mexico, North                                                                                                                                                                                                                                                                                             Stop 830
Dakota, Oregon, Rhode Island, South                                                                                                                                                                                                                                             Andover, MA 01810                                                                                     Part I
Dakota, Tennessee, Utah, Vermont,
Washington, Wisconsin, Wyoming                                                                                                                                                                                                                                                                                                                                                        Line 1a

Missouri,Oklahoma,Kansas,Arkansas,VirginiaMichigan,Nebraska,California,Pennsylvania,Minnesota,NewIndiana,York,WestIowa,Ohio,                                                                                           KansasDepartmentInternalCity, MORevenueofStopthe64999–0250TreasuryP-4Service5000                                                                               LineIfandtaxyoureturn.socialare2         makingsecuritythisnumbersrequest(SSNs)for a jointin thetaxsamereturn,ordershowastheonnamesyour
A foreign country, American Samoa,                                                                                                                                                                                                                                                                                                                                                    If you are requesting an installment agreement for a business tax
or Puerto Rico (or are excluding                                                                                                                                                                                                                                                                                                                                                      liability, enter the business name and employer identification
income under Internal Revenue Code                                                                                                                                                                                              Department of the Treasury                                                                                                                            number on this line.
section 933), or use an APO or FPO                                                                                                                                                                                                                       Internal Revenue Service
address, or file Form 2555, 2555-EZ,                                                                                                                                                                                   3651 South I-H 35, 5501AUSC                                                                                                                                    Line 7

ornonpermanentthe4563,VirginorIslands*areresidenta dual-statusof Guamalienoror                                                                                                                                                                                                                 Austin, TX 78741                                                                       Enternotice(s)).the total amount you owe as shown on your tax return(s) (or
* Permanent residents of Guam or the Virgin Islands cannot use Form                                                                                                                                                                                                                                                                                                                                     If the total amount you owe is greater than $25,000 but not
9465-FS.                                                                                                                                                                                                                                                                                                                                                                                 !              more than $50,000, you must complete Part II and agree to
                                                                                                                                                                                                                                                                                                                                                                                      CAUTION           a Direct Debit Installment Agreement (DDIA) to qualify for
                                                                                                                                                                                                                                                                                                                                                                                      an IA without completing a financial statement. If you do not agree
                                                                                                                                                                                                                                                                                                                                                                                      to a DDIA, you must complete Form 433-F, Collection Information
                                                                                                                                                                                                                                                                                                                                                                                      Statement, and mail it with this form.
                                                                                                                                                                                                                                                                                                                                                                                      If the amount you owe is greater than $50,000, you must complete
                                                                                                                                                                                                                                                                                                                                                                                      Form 433-F and mail it with this form. You can download Form
                                                                                                                                                                                                                                                                                                                                                                                      433-F at IRS.gov or order it by calling 1-800-TAX-FORM
                                                                                                                                                                                                                                                                                                                                                                                      (1-800-829-3676).
                                                                                                                                                                                                                                                                                                                                                                                                        If the total amount you owe is not more than $50,000
                                                                                                                                                                                                                                                                                                                                                                                      TIP               (including any amounts you owe from prior years), you do
                                                                                                                                                                                                                                                                                                                                                                                                        not need to file Form 9465-FS; you can request an
                                                                                                                                                                                                                                                                                                                                                                                      installment agreement online. For more information see Applying
                                                                                                                                                                                                                                                                                                                                                                                      online for a payment agreement, earlier.

                                                                                                                                                                                                                                                                                                                                                                                   -2-



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Page 3 of 3                                                               Instructions for Form 9465-FS                                                                                                                                                                                                                                                                                                                                                                      13:48 - 23-DEC-2011

The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.

Line 8                                                                                                                                                                                                                                                                                                   The electronic funds withdrawal from your checking account
                                                                                                                                                                                                                                                                                                  TIP    will not be approved unless you (and your spouse if filing a
Even if you cannot pay the full amount you owe now, you should                                                                                                                                                                                                                                           joint return) sign Form 9465-FS.
pay as much as possible to limit penalty and interest charges. If you
are filing this form with your tax return, make the payment with your                                                                                                                                                                                                                             Sample Check—Lines 11a and 11b
return. For details on how to pay, see your tax return instructions.
  If you are filing this form by itself, such as in response to a
notice, attach a check or money order payable to the “United States                                                                                                                                                                                                                                 Paul Maple                                                                                                                                                                                                                                                                                      1234
Treasury.” Do not send cash. Be sure to include:                                                                                                                                                                                                                                                    Roberta Maple                                                                                                                            SAMPLE                                                                                                                                 15-0000/0000¶
• Your name, address, SSN/EIN, and daytime phone number.                                                                                                                                                                                                                                            123 Pear Lane 
                                                                                                                                                                                                                                                                                                    Anyplace, VA 20000 
• The tax year and tax return (for example,“ 2009 Form 1040”) for
which you are making this request.                                                                                                                                                                                                                                                                  PAY TO THE 
                                                                                                                                                                                                                                                                                                    ORDER OF                                                                                                                                                                                                                             $
Line 9                                                                                                                                                                                                                                                                                                                                                                    Routing                                                            Account 
Enter on line 9 the amount you can pay each month. Make your                                                                                                                                                                                                                                                                                                              number                                                             number                                                                                                         DOLLARS
                                                                                                                                                                                                                                                                                                                                                                          (line 11a)                                                         (line 11b)
payments as large as possible to limit interest and penalty charges.                                                                                                                                                                                                                                ANYPLACE BANK                                                                                                                                                                                                                                  Do not include 
                                                                                                                                                                                                                                                                                                    Anyplace, VA 20000
The charges will continue until you pay in full. If a payment amount                                                                                                                                                                                                                                                                                                                                                                                                                                                                     the check number.
is not shown on line 9, one will be determined for you by dividing                                                                                                                                                                                                                                  For
the balance due by 72 months.                                                                                                                                                                                                                                                                       |         :250250025                                                  |  :202020"'86".1234 §
Line 10

                                                                                                                                                                                                                                                                                                  TIP
Youcanthe month.becanonchooseorForafterexample,thetheday1stofifofyoureachtherentmonth,monthor mortgagebutyournopaymentlaterpaymentthanis due.theis28thdueThisonof                                                                                                                                        Theon yourroutingcheck.and account numbers may be in different places
the 1st of the month, you may want to make your installment
payments on the 15th. When we approve your request, we will tell
you the month and day that your first payment is due.                                                                                                                                                                                                                                             Part II
  If we have not replied by the date you chose for your first
payment, you can send the first payment to the Internal Revenue                                                                                                                                                                                                                                   Lines 12—24
Service Center at the address shown earlier that applies to you.                                                                                                                                                                                                                                  Complete Part II only if your balance due is greater than $25,000
See the instructions for line 8 above for details on what to write on                                                                                                                                                                                                                             but not more than $50,000.
your payment.
                                                                                                                                                                                                                                                                                                  Privacy Act and Paperwork Reduction Act Notice.                                                                                                                                                                                                                     Our legal
Lines 11a and 11b                                                                                                                                                                                                                                                                                 right to ask for the information on this form is sections 6001, 6011,
                                                                                                                                                                                                                                                                                                  6012(a), 6109, and 6159 and their regulations. We will use the
          Making your payments by electronic funds withdrawal will                                                                                                                                                                                                                                information to process your request for an installment agreement.
TIP       help ensure that your payments are made timely and that                                                                                                                                                                                                                                 The reason we need your name and social security number is to
          you are not in default of this agreement.                                                                                                                                                                                                                                               secure proper identification. We require this information to gain

accountyournumbers.withdrawalbrokerageTofinancialpayatbyfirm,aisbankallowedelectronicinstitutionor creditor otherandfundstounion),tomakefinancialgetwithdrawalfillthesureininstitutioncorrectlinesthatfroman11aroutingelectronic(suchyourand 11b.andcheckingas mutualfundsaccountCheckfund,with   toyouraccessrequiredprovidingagreement.providerequest.totofalsethethisprovideIfYoutaxyouinformationinformationinformationdoaretherequestnotinformationrequiredmaymayinanpreventoursubjectinstallmentrequestedtofilesrequestprocessingyouandtoagreement,properlyonanfinesthisinstallmentyourorform.respondpenalties.request;youFailureareto
                                                                                                                                                                                                                                                                                                    You are not required to provide the information requested on a
          If the total amount you owe is greater than $25,000 but not                                                                                                                                                                                                                             form that is subject to the Paperwork Reduction Act unless the form
CAUTION!  more than $50,000, you must agree to a Direct Debit                                                                                                                                                                                                                                     displays a valid OMB control number. Books or records relating to a
          Installment Agreement (DDIA) to qualify for an IA without                                                                                                                                                                                                                               form or its instructions must be retained as long as their contents
completing a financial statement. If you do not agree to a DDIA, you                                                                                                                                                                                                                              may become material in the administration of any Internal Revenue
must complete Form 433-F, Collection Information Statement, and                                                                                                                                                                                                                                   law. Generally, tax returns and return information are confidential,
mail it with this form.                                                                                                                                                                                                                                                                           as required by section 6103. However, we may give this information
Line 11a.                                    The routing number must be nine digits. The first two                                                                                                                                                                                                to the Department of Justice for civil and criminal litigation, and to
digits of the routing number must be 01 through 12 or 21 through                                                                                                                                                                                                                                  cities, states, the District of Columbia, and U.S. commonwealths
32. Use a check to verify the routing number. On the sample check                                                                                                                                                                                                                                 and possessions to carry out their tax laws. We may also disclose
on this page, the routing number is 250250025. But if your check is                                                                                                                                                                                                                               this information to other countries under a tax treaty, to federal and
payable through a financial institution different from the one at                                                                                                                                                                                                                                 state agencies to enforce federal nontax criminal laws, or to federal
which you have your checking account, do not use the routing                                                                                                                                                                                                                                      law enforcement and intelligence agencies to combat terrorism.
number on that check. Instead, contact your financial institution for                                                                                                                                                                                                                               The average time and expenses required to complete and file
the correct routing number.                                                                                                                                                                                                                                                                       this form will vary depending on individual circumstances. For the
Line 11b.                                    The account number can be up to 17 characters (both                                                                                                                                                                                                  estimated averages, see the instructions for your income tax return.
numbers and letters). Include hyphens but omit spaces and special                                                                                                                                                                                                                                   If you have suggestions for making this form simpler, we would
symbols. Enter the number from left to right and leave any unused                                                                                                                                                                                                                                 be happy to hear from you. See the instructions for your income tax
boxes blank. On the sample check below, the account number is                                                                                                                                                                                                                                     return.
20202086. Do not include the check number.
Note.     We may have filed a notice of federal tax lien against your
property. If so, you may be able to get the notice of lien withdrawn.
To learn more about lien withdrawals and to see if you qualify, visit
IRS.gov and enter ‘‘lien withdrawal’’ in the search box.

                                                                                                                                                                                                                                                                                               -3-






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