Individual Income Tax                                     ARIZONA FORM

                                          Payment Plan Request                                      140-IA
                             • Do not attach Form 140-IA to your original tax return.
                             •    Read the instructions below before completing this form.

Payment Plan Options:
Proposed Monthly Payment Date: ____________  **Payment is due this date each month**
Amount Owed                          Installments
  $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
                — OR —
Proposed Payment Plan:      (Proposed plans are subject to review and may require additional financial documentation.)
$ ____________ for ____________ months

Enter your name(s) and Social Security Number(s) as listed on Arizona Form 140, 140A, 140EZ, 140PY, or 140NR.
Your First Name and Initial                Last Name                                     Your Social Security Number

Mailing Address                            Apt. No. Home Phone Number (with Area Code)   Email

City, Town or Post Office         State ZIP Code    Your Work Phone No. (with Area Code) Spouse’s Work Phone No. (with Area Code)

                                                  INSTRUCTIONS

Terms – Compliance with all terms is required, default on any term can lead to enforcement action:
 •  All payments must be made 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:
 •  You will receive a payment plan confirmation letter if your payment plan is approved.
 •  Pay your monthly installment on or before your proposed payment date until your confirmation letter is received.
 •  ADOR agent may call for more information to approve the payment plan.
 •  The department charges interest from the original due date until the balance is paid in full.
 •  Depending on the amount owed, a tax lien may be filed.
 Submission Options:
 1. Fax completed form to (602) 542-4771
 2. Mail completed form to:  
    Arizona Department of Revenue
    Collections District
    PO BOX 29070
    Phoenix, AZ  85038-9070

  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.

                                                                          Print Form          Clear
ADOR 10153 (12/18)