Kansas Department of Revenue                                                    310019
                               PAY PLAN REQUEST FOR INDIVIDUALS
                                https://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

Name:                                                                SSN:

Spouse Name:                                                         Spouse SSN:

Street Address:                                                      Daytime phone:

City:                                                                         State:                   Zip Code:

Email address:

BALANCE DUE AND PAYMENT TERMS

Amount to be paid each month: $          Payment Date(s):  1st         15th    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 draft.

Bank name:

Street address:

City:                                                                    State:                        Zip Code:

9-digit Routing number:                                        Account number:

Do you want automatic payments taken out of your bank account?  Yes  No

SIGNATURES

Print this form and sign here: 

Signature:                               Spouse’s Signature:

Printed Name:                            Printed Name:

CM-15
(Rev. 5-23)

                  INSTRUCTIONS FOR COMPLETING AND SUBMITTING APPLICATION

Taxpayer Information: Enter the requested information. If married, you must enter your spouse’s information. Remember
to enter the area code 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 payment plan is
        approved, the first payment may include an additional $25.00 administration fee for plans exceeding 90 days. You will
        receive a payment 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 that are 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.
Employer Information: Enter your employer information. If you are married, enter your spouse’s employer information.
Banking Information:
   •    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.
   •    Automatic Withdrawals. Once your payment plan is approved, you can authorize the department to take automatic
        withdrawals by answering “Yes” to the automatic payment question. Payment withdrawals will be taken on the dates that
        you specified in the “Payment Date(s)” line completed on the application.
Signatures: Your application will not be accepted unless the document is signed.   A signature from your spouse is required 
if spouse information is contained on the application.
Incomplete or missing information will result in delaying the processing of this request. This form can be faxed to 
785-291-3616 or emailed toKDOR_kstaxpayplanrequest@ks.gov or mailed to the below address:
                                                Kansas Department of Revenue
                                                       Revenue Recovery
                                                        PO Box 12005
                                                    Topeka, KS 66601-2005

                                              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 their installment payments on time.
A tax warrant must be filed with the District Court for pay plans over 12 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 Social Security Number on your check
        or money order and make it payable to “Kansas Income Tax.”
   •    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 website at https://debtpay.kdor.ks.gov/iia
   •    Credit Card. To pay by credit card you must visit one of the service provider’s websites. 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
        website: https://officialpayments.com
   •    Wage Assignment. To make payment arrangements utilizing a wage assignment(s)through your employer please call
        785-296-6121 for information.