Kansas Department of Revenue                                                    310119
                                 PAY PLAN REQUEST FOR BUSINESSES 
                                    https//www.ksrevenue.gov/payplan.html 

IMPORTANT: Save time and paper by completing your payment plan application electronically. Go to https://debtpay.kdor.ks.gov/iia 

TAXPAYER INFORMATION 

Business Name:                                                   SSN/EIN: 

Contact Name: 

Street Address:                                                 Daytime phone: 

City:                                                                         State:              Zip Code: 

Email address: 

BALANCE DUE AND PAYMENT TERMS 

                                                                st       th
Amount to be paid each month: $               Payment Date(s):  1   15  Other
                                                                                                            Date(s) 
Enter number of payments:                      Amount enclosed with this request:  $ 

Tax Type:                            Periods:                                   Estimated Balance: $ 

Tax Type:                            Periods:                                   Estimated Balance: $ 

Tax Type:                            Periods:                                   Estimated Balance: $ 
                                0.00
Estimated Total Balance Due $ 

BANKING INFORMATION – Information provided here will not generate an automatic withdrawal. 

Bank Name:  
Street Address: 
City:                                                                 State:                      Zip Code: 
9-digit Routing number:                                Account number:   

SIGNATURES: Print this form and sign here: 

Signature: 

Printed Name: 

CM-16 (Rev. 9-19)

Instructions for completing and submitting form 

Taxpayer Information: Enter the business name, contact name, phone and address information. Remember to enter 
the area number when entering your phone number. 
Balance Due and Payment Terms: 
     Amount to be paid each month- Enter the amount to be paid each month.
     Payment Date(s)  - Check the appropriate payment date. If “Other” is selected, enter the date in which the
      payment will be due.
     Enter number of payments – Based on the estimated balance due and the amount to be paid each month,
      enter the number of payments that will be made.
     Amount enclosed with this request           – Enter the amount that you are enclosing with this request. If your pay
      plan is approved, the first payment may include an additional $25.00 administration fee for plans exceeding 90
      days. You will receive a pay plan confirmation by mail within 14 days once your request has been processed.
     Tax Type, Periods and Estimated Balance- If you know what tax types, periods and estimated balances are
      that make up your total balance due, enter the information. If unknown, enter an amount in the Estimated Total
      Balance Due line. If you are sending a payment with the application, enter the amount on the appropriate line.
Banking Information: This information will not be used to generate an automatic withdrawal from your bank account. 
     Enter your bank name and address.
     Routing Number – The 9-digit number is located on the bottom of your check and is the first set of numbers.
     Account Number – The account number is located on the bottom of your check and is the last set of numbers.

Signature: Your application will not be accepted unless the document is signed.  
Incomplete or missing information will result in delaying the processing of this request. This form can be faxed to (785) 
291-3616 or emailed to kstaxpayplanrequest@kdor.ks.gov or mailed to the below address:
                                                          Compliance Enforcement  
                                                 Kansas Department of Revenue 
                                                              PO Box 3506
                                                          Topeka, KS 66601-3506
General Information 
The Kansas Department of Revenue may consider a payment plan agreement for taxpayers to resolve their accounts if 
certain criteria are met. Taxpayers who are granted a payment plan must file and pay all current and future taxes and 
estimated payments when due. Any additional debts not included in the agreement or missed payments will be 
considered default of the agreement and KDOR may take immediate enforcement action. 
Penalty and interest will continue to accrue during the life of the agreement based upon any unpaid tax. Any refunds or other 
monies due to the taxpayer will be applied to the liability, even if the taxpayer is/has made all of their installment payments on 
time. 
A tax warrant must be filed with the District Court for pay plans over 6 months. A tax warrant will also be filed if the Statute of 
Limitations is due to expire during the term of the payment plan. 
If your payment plan is denied, you will receive instructions from KDOR on how to proceed. 
Once a payment plan is set, you may choose from one of the following three options offered by KDOR to pay your 
tax: 
     Check or Money Order. If you choose this payment method, be sure to write your SSN or EIN on your check or money
      order and make it payable to “Kansas Department of Revenue.”
     Direct Payment. When you select Direct Payment, you are giving KDOR permission to initiate a payment
      electronically from your bank account. This Direct Payment option is not recurring; you will need to authorize
      each payment separately. For more information, visit our web site at: https://debtpay.kdor.ks.gov
     Credit Card. To pay by credit card you must visit one of the service provider’s web sites. A convenience fee will be
      charged by the service provider based on the amount of tax you are paying. You can find out what the fee is by visiting
      their web site: www.officialpayments.com

      Wage Assignment.    To make payment arrangements utilizing a wage assignment(s) through your employer 
      please call (785) 296-6121 for information. 

CM-16 (Rev. 06/17)