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Form STATE OF HAWAII – DEPARTMENT OF TAXATION
D-100 REQUEST FOR AN INSTALLMENT PLAN AGREEMENT
(Rev. 2021) (You may also log on to your Hawaii Tax Online (HTO) account at hitax.hawaii.gov to set up a payment plan.
A Case number will be required to establish an installment plan.)
1 Taxpayer Name: SSN/FEIN:
DBA Name: Case Number(s):
Mailing Address:
Daytime Phone
Number: Other Phone Number:
Name of your bank(s) or
2 other financial institution(s):
Primary’s Place of
employment: Monthly gross income:
Spouse’s Place of
employment: Monthly gross income:
Do you own real property? Yes No If yes, where is it located?
□ □ (City/State or Country)
Household size:
3 Enter the amount you can pay each month:
Enter the day of the month your payments will be due (e.g. on 15th of each month):
* Your proposal will be reviewed based on the terms shown above, however, the Department reserves the right to request further information,
including financial substantiation. If the amount you owe is over $25,000.00 and your installments will be longer than 12 months, please
submit a CM-2 (Statement of Financial Condition – Individuals) or CM-2B (Statement of Financial Condition – Corp, Partnerships, etc.)
4 METHOD OF PAYMENT:
Pay by Electronic Funds Withdrawal
(This is the most convenient way to make your installment payments and it ensures your installments are made on time.)
● Include a VOIDED CHECK with this form.
● Installment payments will be debited from your bank account on the payment due date, or on the next business day if the
due date falls on the weekend or holiday
Pay by Check or Online
● Installment payments must be made timely. Check or money order must be in U.S. dollars payable to the Hawaii State Tax
Collector. For online payments please visit our portal at hitax.hawaii.gov.
5 I have read and understood the General Instructions stated on the back of this form. If the “Pay by Electronic Funds Withdrawal” box above is checked, I (we)
hereby authorize the State of Hawaii Department of Taxation (DOTAX) and its designated financial agent to initiate an ACH electronic funds withdrawal entry
to the financial institution indicated for payment of my State taxes owed, and the financial institution to debit the entry to this account. This authorization is to
remain in full force and effect until I (we) notify the State of Hawaii Department of Taxation to terminate the authorization. To discontinue the electronic funds
withdrawal, I (we) must contact DOTAX at the telephone numbers listed on the back of this form, no later than seven (7) business days prior to the payment
(settlement) date. I (we) also authorize the financial institution involved in the processing of the electronic payments of taxes to receive confidential information
necessary to answer inquires and resolve issues related to the payments.
Print Name of Owner, Partner/Member, Officer, or Agent Signature of Owner, Partner/Member, Officer, or Agent Date
D100_I 2021A 01 VID01 Form D-100 (Rev. 2021)
