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OMB No. 1545-2131
Form 1127-A Application for Extension of Time for Payment of
Department of the Treasury Income Tax for 2011 Due to Undue Hardship 2011
Internal Revenue Service
Before you begin: See Who Should File in the instructions.
Your first name and initial Last name Your social security number

If a joint return, spouse's first name and initial Last name Spouse's social security number

Home address (number and street). If you have a P.O. box, see instructions. Apt. no.

City, town, or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions)

Foreign country name Foreign province/county/state Foreign postal code

Part I Eligibility Requirements
Filing Status Single Head of household
Check only Married filing jointly (even if only one had income) Qualifying widow(er)
one box Married filing separately
1 Adjusted gross income—Enter the amount of your adjusted gross income (AGI) from your 2011
Form 1040, line 37 (Form 1040A, line 21, or Form 1040EZ, line 4) . . . . . . . . . . . 1. $
Note. To qualify for this extension, your AGI must be less than $100,000 ($200,000 if married filing
jointly).
2 Amount you owe—Enter the amount you owe from your 2011 Form 1040, line 76 (Form 1040A, line
45, or Form 1040EZ, line 12) . . . . . . . . . . . . . . . . . . . . . . . 2. $
Note. You must owe less than $50,000 to qualify for this extension.
Part II Reason for Extension
I request an extension of time to pay my income tax for 2011 because (check one of the following):
I have been unemployed, or my spouse has been unemployed (if filing a joint return), for at least 30 consecutive days during 2011
or 2012, prior to April 15, 2012.
I am self-employed and need an extension of time to pay due to a 25% or greater reduction in business income in 2011 (relative to
2010) due to the economic downturn.
Part III Terms for Granting the Extension. By submitting this application, I have read, understand, and agree to the
following terms and conditions.
Terms, I understand that this request for an extension of time to pay applies only to income tax owed for 2011.
Conditions, I understand that if this request for an extension of time to pay is granted, it will only affect the failure-to-pay penalty.
and Legal I understand that even if this extension of time to pay my income tax is granted, I will still owe interest and any other
Agreement penalties on the unpaid amount from April 15, 2012, until the tax is paid in full.
I understand that in order for this extension to be granted, the full amount of the income tax that I owe, plus interest
and any other penalties, must be paid on or before the extension due date of October 15, 2012.
I understand that I must file my 2011 income tax return by April 17, 2012 (October 15, 2012, if an extension to file was
requested by filing Form 4868, Application for Automatic Extension of Time To File U.S. Individual Income Tax Return).
Note. The IRS will notify you only if your application is not approved.
Failure to I understand that if full payment of the amount of the tax for which I am requesting this extension, plus interest and
pay the full other penalties, is not paid on or before the payment extension date, a failure-to-pay penalty will be imposed and
amount by calculated from the original payment due date, April 15, 2012. (See instructions.)
the payment
extension
date

Signature and Verification
Under penalties of perjury, I declare that I have examined this application, and to the best of my knowledge and belief, it is true, correct, and complete; and, if
prepared by someone other than the taxpayer, that I am authorized to prepare this form.
Signature of taxpayer ▶ Date ▶

Signature of spouse ▶ Date ▶
Signature of preparer
other than taxpayer ▶ Date ▶

For Privacy Act and Paperwork Reduction Act Notice, see instructions. Cat. No. 58934X Form 1127-A (2011)

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Form 1127-A (2011)                                                 Page  2 
                   FOR IRS USE ONLY 

This application is not approved for the following reason(s).

                   Signature of authorized IRS official      Date 
                                                             Form  1127-A  (2011)

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Form 1127-A (2011) Page 3
Section references are to the Internal Revenue Code. Where To File
Mail Form 1127-A to the address shown below that applies to you.
General Instructions Do not attach this form to your return or mail it to the address for
Purpose of Form your tax return.
Use Form 1127-A to ask for an extension of time to pay the income IF you live in . . . THEN mail Form 1127-A to . . .
tax due, or to be shown as due, on your Form 1040, Form 1040A, or Alabama, Alaska, Arizona, Internal Revenue Service
Form 1040EZ for 2011. See Who Should File, next, to determine if Arkansas, Colorado, Connecticut, P.O. Box 480
you are eligible to use this form. The granting of this request for an Delaware, District of Columbia, Stop 662-X
extension of time to pay will only result in relief from the failure-to- Hawaii, Idaho, Indiana, Iowa, Holtsville, NY 11742-0480
pay penalty and only if the tax, interest, and any other penalties are Kansas, Kentucky, Louisiana,
fully paid by October 15, 2012. Maine, Maryland, Massachusetts,
Form 1127-A does not extend the time to file your 2011 Minnesota, Mississippi, Missouri,
income tax return. To get an extension of time to file, you Montana, Nebraska, Nevada, New
▲! must file Form 4868, Application for Automatic Extension Hampshire, New Jersey, New
CAUTION of Time To File U.S. Individual Income Tax Return. Mexico, New York, North Dakota,
Oklahoma, Oregon, Pennsylvania,
Future developments. The IRS has created a page on IRS.gov for Rhode Island, South Carolina,
information about Form 1127-A and its instructions at www.irs.gov/ South Dakota, Tennessee, Utah,
form1127. Information about future developments affecting Form Vermont, Virginia, Washington,
1127-A (such as legislation enacted after we release it) will be West Virginia, Wisconsin,
posted on that page. Wyoming
Who Should File California, Florida, Georgia, Illinois, Internal Revenue Service
You are eligible for an extension of time to pay your income tax for Michigan, North Carolina, Ohio, P.O. Box 24035
2011 if you meet the following requirements: Texas Stop 81208
1. Your income tax liability for 2011, as shown or to be shown on Fresno, CA 93779-4035
your Form 1040, 1040A, or 1040EZ, is less than $50,000. A foreign country, U.S. possession Internal Revenue Service
2. Your adjusted gross income, as shown or to be shown on your or territory, or use an APO or FPO 5000 Corporate Dr.
Form 1040, 1040A, or 1040EZ, is less than— address. Holtsville, NY 11742
a. $100,000, if your filing status is single, married filing
separately, head of household, or qualifying widow(er), or Extension Period
b. $200,000, if you are filing a joint return. The extension of time to pay your income tax liability is conditioned
3. You are experiencing economic hardship and need a six-month upon your paying the full amount of tax, interest, and penalties
extension of time to pay your income tax for 2011 because— (other than the failure-to-pay penalty) due on or before the October
15, 2012, extension date. The granting of this request for an
a. You were or your spouse (if filing a joint return) was extension of time to pay will only result in relief from the
unemployed for at least 30 consecutive days during 2011 or failure-to-pay penalty.
2012, prior to April 15, 2012, or Note. The IRS will notify you only if your application is not
b. You are self-employed and you suffered a 25% or greater approved.
reduction in business income in 2011 (relative to 2010) due
to the economic downturn. Payment Due Date
Note. If you are requesting to postpone payment of tax shown on a You must pay in full all tax, interest, and penalties (other than the
return (other than a tax shown on Form 1040, 1040A, or 1040EZ) or failure-to-pay penalty) on or before October 15, 2012. Do not wait
an amount determined as a deficiency, see Form 1127. to receive a bill from the IRS.
When To File Interest. You will owe interest on any tax not paid by April 15, 2012,
regardless of whether an extension of time to pay the tax has been
Your Form 1127-A must be postmarked on or before April 17, 2012. obtained. The interest runs until you pay the tax.
Penalties. If you fail to pay the full amount of all tax, interest, and
penalties (other than the failure-to-pay penalty) on or before
October 15, 2012, the penalty for failure to pay will be imposed as
of the original payment due date (April 15, 2012).

Specific Instructions
Name, Address, and Social Security Number
Enter your name, address, and social security number (SSN) or
individual taxpayer identification number (ITIN). If this application is
for the tax shown on a joint return, include both spouses’ names in
the order in which they appear or will appear on your return.
P.O. box. Enter your box number only if your post office does not
deliver to your street address.
Foreign address. If you have a foreign address, enter the city name
on the appropriate line. Do not enter any other information on that
line, but also complete the spaces below that line. Do not
abbreviate the country name. Follow the country's practice for
entering the postal code and the name of the province, county, or
state.

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Form 1127-A (2011) Page 4
Part I. Eligibility Requirements Privacy Act and Paperwork Reduction Act Notice. We ask for
Filing Status. Check the box indicating the filing status you are the information on this form to carry out the Internal Revenue laws
claiming on your 2011 Form 1040, Form 1040A, or Form 1040EZ. of the United States. We need this information to ensure
compliance with these laws and to properly grant extensions of
Adjusted Gross Income. Enter your adjusted gross income (AGI) time to pay tax. Applying for an extension of time for the payment of
from your 2011 Form 1040, line 37 (Form 1040A, line 21, or Form tax is voluntary. However, providing the requested information is
1040EZ, line 4). mandatory if you apply for the extension. Our legal right to ask for
Note. To qualify for this extension, your AGI must be less than the information requested on this form is based in sections 6001,
$100,000 ($200,000 if married filing jointly). 6011, 6109, and 6161 and their regulations. If you fail to provide all
Amount you owe. Enter the amount you owe from your 2011 Form or part of the information requested, your application may be
1040, line 76 (Form 1040A, line 45, or Form 1040EZ, line 12). denied. If you provide false or fraudulent information, you may be
subject to penalties.
Note. You must owe less than $50,000 to qualify for this extension.
You are not required to provide the information requested on a
Part II. Reason for Extension form that is subject to the Paperwork Reduction Act unless the
Check the appropriate box indicating the reason you need an form displays a valid OMB control number. Books or records
extension of time to pay your 2011 income tax liability. relating to a form or its instructions must be retained as long as
their contents may become material in the administration of any
Part III. Terms for Granting the Extension Internal Revenue law. Generally, tax returns and return information
Failure to pay the full amount by the payment extension date. are confidential, as required by section 6103. However, section
You will receive a notice and demand for payment that is 6103 allows or requires the Internal Revenue Service to disclose
automatically generated when you file your return and the amount the information to others as described in the Code. For example,
shown due on the return is assessed. You may disregard the we may disclose this information to the Department of Justice for
payment due date on that notice unless the IRS notifies you that enforcement of civil or criminal tax laws; to cities, states, the
your request for an extension of time has not been approved. District of Columbia, and U.S. commonwealths or possessions to
administer their tax laws; to other countries under a tax treaty; to
Signature and Verification federal and state agencies to enforce non-tax criminal laws; or to
This form must be signed and dated. federal law enforcement and intelligence agencies to combat
If this application is for the income tax shown on a joint return, terrorism.
both you and your spouse must sign and date this form. If your The time needed to complete and file this form will vary
spouse cannot sign, see Pub. 501. depending on individual circumstances. The estimated burden for
taxpayers who file this form is shown below.
Contacting the IRS Recordkeeping . . . . . . . . . . . . . . 6 min.
If you have questions regarding your eligibility for an extension of Learning about the
time to pay, please call our toll-free number at 1-800-829-1040 law or the form . . . . . . . . . . . . . . 15 min.
(hearing impaired customers with access to TTY/TDD equipment Preparing and sending
may call 1-800-829-4059) or visit our website at the form to the IRS . . . . . . . . . . . . . 58 min.
www.irs.gov/freshstart.
If you have comments concerning the accuracy of these time
Ordering Forms and Publications estimates or suggestions for making this form simpler, we would
You can get forms and publications by calling 1-800-TAX-FORM be happy to hear from you. See the instructions for the tax return
(1-800-829-3676), or by visiting your local IRS office or our website for which this form is filed.
at IRS.gov.
Low Income Taxpayer Clinics
Low Income Taxpayer Clinics (LITCs) are independent from the IRS.
Some clinics serve individuals whose income is below a certain
level and who need to resolve a tax problem. These clinics provide
professional representation before the IRS or in court on audits,
appeals, tax collection disputes, and other issues for free or for a
small fee. Some clinics can provide information about taxpayer
rights and responsibilities in many different languages for individuals
who speak English as a second language. For more information and
to find a clinic near you, see the LITC page on
www.irs.gov/advocate or IRS Publication 4134, Low Income
Taxpayer Clinic List. This publication is also available by calling
1-800-829-3676 or at your local IRS office.

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