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                                                                         Utah State Tax Commission
                                                                 Individual Income Tax                                                       TC-804
                                                                                                                                             Rev. 4/13
                                                            Payment Agreement Request

                                                                                               Get forms online - tax.utah.gov

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

Your full name (first, middle, last)                                                                              Your social security number

If a joint return, spouse's full name (first, middle, last)                                                       Spouse's social security number

Your current address                                                                                              Daytime telephone number

                                                                                                                  Evening telephone number

                                                                                                                  Email address (required for pay plan reminders)

Your 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.
Your signature                                              Date Spouse’s signature (if joint return, both must sign)                            Date

If you need an accommodation under the Americans with Disabilities Act, contact the Tax Commission at 801-297-3811
or Telecommunications Device for the Deaf 801-297-2020. Please allow three days for a response.

Purpose of Form                                         Form Instructions
Use this form to request a monthly payment plan if      If you are making this request for a joint filed return,
you cannot pay the full amount you owe on your          enter the names and social security numbers in the
individual income tax return (or on a billing notice    same order as they appear on your tax return, your
we sent you). Generally, you may have up to 24          telephone numbers and email address.
months to pay. However, it is better to pay the
amount you owe as soon as you can to reduce the         Line 3
amount of interest you will pay.                        Enter any payment amount being paid with the
                                                        return or billing notice. Pay as much as possible to
NOTE: A payment plan for business taxes is              lower the amount of penalty and interest you will be
requested on form TC-804B.                              assessed.

Bankruptcy                                              Line 4
If you are in bankruptcy do not use this form.          Enter the amount you can pay monthly. Even if you
Instead, call 801-297-6219 or if you are out of the     cannot pay the full amount you owe now, pay as
Salt Lake area 1-800-662-4335 extension 6219.           much as possible each month to lower the amount
                                                        of penalty and interest you will be assessed.
How Does the Agreement Process Work?
If your request is approved, we will send you an        Late filing, late payment and extension penalties
email. The email will confirm your monthly payment      may apply. Interest will be assessed and continue
amount and the number of required payments. It          to accrue until the amount owed is paid in full.
will also explain how to make your first payment.       Penalty and interest information is available online
You will have the following payment options:            at incometax.utah.gov.

1. Pay by mail with check or money order.               Line 5
2. Pay in person at one of our offices.                 Enter the day of the month you want the payment
3. Pay by Internet at taxexpress.utah.gov.              due. This is the day the payment must be received
a. Electronic check (direct debit) from your            by the Tax Commission. Note: If you are mailing
           checking or savings account.                 your payment, allow 3 to 5 days for mail delivery.
b. Credit card (American Express Discover,
           Card, MasterCard and Visa). You will be      Line 6
           charged a fee each time you use this         You must have filed a return for all prior years. List
           method of payment. The fee is based on       the years for which you have not filed an income tax
           a percentage of the payment made.            return. If you are unable to file a return due to lost
                                                        records you need to estimate your liability. Your
By approving your request we agree to let you pay       payment agreement will not be approved until all
the tax you owe in monthly payments instead of          returns have been filed. If you have questions
immediately paying the tax in full. In return you       contact us at 801-297-7703.
agree to make your monthly payments on time. You
also agree to meet all of your future tax               Signatures
liabilities. This means that you must have enough       If you are filing a request for a joint filed return, the
withholding or prepayments so that your future tax      signatures of both taxpayers are required.
liability is paid in full when you file a timely return.
                                                        Submit to:
Any future year refunds due you from the Internal
Revenue Service or the State will be applied                  Utah State Tax Commission
against the amount you owe.                                   210 N 1950 W
                                                              SLC, UT 84134-7000
Important Note: Failure to make your payments on
                                                        or fax form to: 801-297-6202
time or failure to file and/or pay future returns when
due, will break your payment agreement. If you          Email Address Note: All communication on pay
break the agreement we can take action to collect       plan is by email. Include your email address where
the tax you owe in full and place liens on your real    indicated. The email address will be used to send
and tangible personal property.                         you notice of approval and to remind you of your
                                                        pay plan.