INSTALLMENT PLAN AGREEMENT

                                                      Log Number  _______________________

Name  ______________________________________________  Account Balance  ___________________

Doing Business As  ___________________________________  Amount of Offer  ____________________

Employer Payroll Tax Account Number  __________________ Date  ______________________________

I promise to satisfy the amount offered, by paying the sum of $ ___________________________________.
I understand that the initial payment of $ _________________ is due on  ___________________________.
Subsequent installments in the amount of $ ________________  will be paid on the same day of each 
succeeding  ____________________________________________ until the entire amount has been paid 
in full.

I further understand that failure to pay as promised will result in termination of the Offer in Compromise, 
and monies paid to the Employment Development Department will be applied against the total liability.

I certify that I have read and fully understand the conditions and terms of this agreement as stated on the 
Installment Plan Information Sheet.

___________________________      ___________________________ ___________________________
Signature Title                                              Date

DE 999D Rev. 2 (2-19) (INTERNET)          Page 1 of 2            CU

                                 INSTALLMENT PLAN INFORMATION SHEET

INTRODUCTION

The Offer in Compromise program allows for installment payments under an agreement not to exceed 
five years.

ABILITY TO PAY

An installment plan will be considered ONLY if you demonstrate the inability to pay the compromised 
amount in full.

REQUIREMENT OF PARTIAL PAYMENT

Your offer must not exceed a five year period. Payment must be submitted in the form of cash (do not 
send cash through the mail), cashier’s check, or money order.

All payments made with this offer are submitted voluntarily. In the event an offer is not accepted, the 
amount will either be applied to the liability or refunded at the discretion of the employer or individual 
submitting the offer.

When entering into a partial payment agreement to satisfy the amount offered and the applicant defaults, 
the agreement will be rescinded. All compromised liabilities and liens will be reestablished without 
regard to the statute of limitations. All monies paid on the compromised amount will be applied to the 
reestablished liability.

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