INSTALLMENT PLAN AGREEMENT 
 
                                                                                               Log No.  _________________  
 
Name  _____________________________________   Account Balance  __________  
 
DBA   ______________________________________   Amount of Offer  ___________  
 
Account No.   ________________________________   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. 
 
By ____________________   Title  _________________   Date  _________________  
 
                                     (over) 
 
DE 999D Rev. 1 (1-15) (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 and the applicant defaults, the agreement will be rescinded.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. 
 
DE 999D Rev. 1 (1-15) (INTERNET)                                                  Page 2 of 2