ARIZONA FORM 
                                          Individual Income Tax 
                                                                                                     140-IA
                                          Payment Plan Request 
                                     Do not attach Form 140-IA to your original tax return
                                     Read the instructions  below before completing this form

INSTRUCTIONS 
Terms – Compliance with all terms is required, default on any term can lead to enforcement action: 
• You must make all payments on www.AZTaxes.gov. - Payments are not taken over the phone
• All payments must be made timely
• Future balances cannot be added to this agreement
• Return payments and insufficient funds will cause your payment plan to cancel and a $50.00 Return Payment
  Penalty will be added to the account
• You may pay in full or make additional payments at any time
Expectations: 
• Once you receive your confirmation letter, make your monthly installment payment on or before your proposed 
  payment date
• If necessary, a ADOR agent may call you for more information to approve the payment plan
• Interest is charged from the original due date until the balance is paid in full
• Depending on the amount owed, a tax lien may be filed against your personal property
Submission Options: 
  Fax completed form to (602) 542-4771 or Mail completed form to: Arizona Department of Revenue 
                                                                Collections District 
                                                                PO Box 29070 
                                                                Phoenix, AZ 85038-9070 

Step 1: Choose a Payment Plan Option 
              Amount Owed             Installment Terms 
          $100 or less                Payment in full required, no payment plan available 
          $101 to $1,000              6 month installment plan 
          $1,001 to $2,500            9 month installment plan 
          $2,501 to $4,999            12 month installment plan 
          $5,000 or greater           Call (602) 542-5551 

To calculate the payment amount, take the balance and divide it by the number of installments. 
 Your monthly payment will be: $___________ 

Step 2:  Choose a Monthly Due Date ___________    *NO further reminders will be sent* 

Step 3: Names(s) and Social Security Number(s) as listed on Arizona Form 140, 140A, 140EZ, 140PY or 140NR 
Last Name, First Name and Initial                            Your Social Security Number 

Spouse First Name and Initial                                Spouse Social Security Number 

Mailing Address                                  Apt. No     City, State and Zip Code 

Area Code and Phone Number                                   Spouse Area Code and Phone Number 

      I have read all terms and expectations. 

      I understand that if I default on this payment plan, the state can and will enforce, which could include tax 
      liens, or wage and bank levies. 

Signature and Date                                 Spouse Signature and Date 

                                                 ADOR 10153 
                                                 (6/2019)