Clear form
                                                                          Utah State Tax Commission
                                                                  Individual Income Tax                                                      TC-804
                                                                                                                                             Rev. 1/19
                                                                  Payment Agreement Request

                                                                                     Get forms at tax.utah.gov/forms

DO NOT use this form if you are currently making payments on an existing payment agreement. Instead, call 801-297-7703 or 1-800-662-4335, ext. 7703
Full name (first, middle, last)                                                                               Social Security number

If a joint return, spouse’s full name (first, middle, last)                                                   Spouse’s Social Security number

Address                                                                                                       Daytime telephone number

                                                                                                              Evening telephone number

                                                                                                              Email address (required for pay plan reminders)

Employer(s) name, address and telephone number                    Spouse’s employer(s) name, address and telephone number

TIP: If you are submitting this form in response to a billing notice, do not complete lines 1 through 3. Instead, attach the bottom section 
of the billing notice to this form and complete lines 4 through 6.

1.  Enter the income tax year for which you are making this request (example, “2011”)–––––––––––––

2.  Enter the total amount you owe as shown on your income tax return –––––––––––––––––––––––– $

3.  Enter the amount of any payment you are making with your tax return or notice. ––––––––––––––– $
 Make your payment as large as possible to limit penalty and interest charges.

4.  Enter the amount you can pay each month. Your payment should be large enough to pay off –––––
 the tax due, penalty and interest within 24 months. Late filing, late payment and extension
 penalties may apply. Interest will be assessed and continue to accrue until the amount owed
 is paid in full. Penalty and interest information is available online at incometax.utah.gov.

5.  Enter the day of the month you want your payments to be due (example, “5th day” of each  ––––––
 month). Your payment must be received on or before the payment due date.

6.  You must have filed income tax returns for all prior years before your pay plan will be approved.
 If you have not, list the year(s) not filed and date you will be filing the returns.

Note: To enter into a pay plan you must file and pay future taxes on time and make your monthly pay plan payments to the Tax 
Commission by the due date. If you do not meet these conditions, you default on your pay plan and are subject to additional 
penalty, interest and fees. The Tax Commission may also record liens, garnish your wages and bank accounts, take and sell 
your property, or refer your account to a collection agency.

I have read and understand the requirements of this request.
Signature                                                   Date  Spouse’s signature (if joint return, both must sign)                       Date

                                If you need an accommodation under the Americans with Disabilities Act, email taxada@utah.gov,
                                 or call 801-297-3811 or TDD 801-297- 2020. Please allow three working days for a response.

Purpose of Form                                                Form Instructions
Use this form to request a monthly payment plan if you         If you are making this request for a joint filed return, 
cannot pay the full amount you owe on your individual          enter the names and Social Security numbers in the 
income tax return (or on a billing notice we sent you).        same order as they appear on your tax return, your 
Generally, you may have up to 24 months to pay.                telephone numbers and email address.
However, it is better to pay the amount you owe as             Line 3
soon as you can to reduce the amount of interest you           Enter any payment amount being paid with the return 
will pay.                                                      or billing notice. Pay as much as possible to lower the 
NOTE: A payment plan for business taxes is requested           amount of penalty and interest you will be assessed.
on form TC-804B.                                               Line 4
Bankruptcy                                                     Enter the amount you can pay monthly. Even if you 
If you are in bankruptcy do not use this form. Instead,        cannot pay the full amount you owe now, pay as much 
call 801-297-6219 or if you are out of the Salt Lake           as possible each month to lower the amount of penalty 
area 1-800-662-4335 ext. 6219.                                 and interest you will be assessed.
How Does the Agreement Process Work?                           Late filing, late payment and extension penalties may 
If your request is approved, we will send you an email.        apply. Interest will be assessed and continue to accrue 
The email will confirm your monthly payment amount             until the amount owed is paid in full. Penalty and inter-
and the number of required payments. It will also              est information is available online at 
explain how to make your first payment. You will have          incometax.utah.gov.
the following payment options:                                 Line 5
 1.  Pay by mail with check or money order.                    Enter the day of the month you want the payment due. 
 2.  Pay in person at one of our offices.                      This is the day the payment must be received by the 
 3.  Pay by Internet at tap.utah.gov.                          Tax Commission. Note: If you are mailing your 
  a.  Electronic check (direct debit) from your                payment, allow 3 to 5 days for mail delivery.
          checking or savings account.                         Line 6
  b.  Credit card (American Express, Discover                  You must have filed a return for all prior years. List the 
          Card, MasterCard and Visa). You will be              years for which you have not filed an income tax return. 
          charged a fee each time you use this                 If you are unable to file a return due to lost records you 
          method of payment. The fee is based on a             need to estimate your liability. Your payment agreement 
          percentage of the payment made.                      will not be approved until all returns have been filed. If 
By approving your request we agree to let you pay the          you have questions contact us at 801-297-7703.
tax you owe in monthly payments instead of immediate-          Signatures
ly paying the tax in full. In return you agree to make         If you are filing a request for a joint filed return, the 
your monthly payments on time. You also agree to               signatures of both taxpayers are required.
meet all of your future tax liabilities. This means that 
you must have enough withholding or prepayments so             Submit to:
that your future tax liability is paid in full when you file a       Utah State Tax Commission
timely return.                                                       210 N 1950 W
Any future year refunds due you from the Internal                    SLC, UT 84134-7000
Revenue Service or the State will be applied against           or fax form to: 801-297-6202
the amount you owe.
                                                               Email Address Note: All pay plan communication is 
Important Note: Failure to make your payments on               done through email. Include your email address where 
time or failure to file and/or pay future returns when         indicated. The email address will be used to send you 
due, will break your payment agreement. If you break           notice of approval and to remind you of your pay plan.
the agreement we can take action to collect the tax you 
owe in full and place liens on your real and tangible 
personal property.