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                                       Form                                                            (MM/DD/YY)
                                       4338        Tax Payment Installment Agreement Request
                                                      Select One :          Income Tax                 Business Tax 

Social Security Number                                                                            Missourri Tax ID Number

                                                 -       -
Taxpayer Name                                                                                     Business Name

Spouse’s Social Security Number                                                                   Federal Employer ID Number

                                                 -       -
Spouse’s Name                                                                                     Authorized Representative

In the event that you are unable  to  pay the entire tax amount due in full, a tax payment installment agreement may be requested online at 
dor.mo.gov/taxation/payment-options/ or by submitting this completed form. Before a payment agreement can be considered, all tax returns must be 
filed. If you need to file return(s), the fastest way is to file on-line at dor.mo.gov or you can attach your return(s) to this request.
A payment plan can be established for no longer than 36 months and the monthly amount cannot be less than $50. All delinquencies on your account 
must be included in the installment agreement. We encourage you to make your payments as large as possible as interest continues to accrue for the 
length of the agreement.
Do not file this form if you are currently making payments on an installment agreement.

                                       Address                                                    City                       State ZIP Code

                                       Daytime Telephone Number             Tax Year(s)/Period(s)      Total Amount Shown On Your Tax Return(s) or Notice(s)
                                       (__ __ __) __ __ __ - __ __ __ __
                                       Requested Down Payment               Requested Monthly Payment  Requested Monthly Payment Due Date (MM/DD/YYYY)
                  Taxpayer Information                                                                         ___ ___ / ___ ___ / ___ ___ ___ ___

                                       Complete the following checking account information if you would like to make your payments by electronic funds withdrawal. 

                                       Name of Your Bank or Other Financial Institution 

                                       Routing Number                       Account Number

                  Electronic Payment

                                       Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct.  I authorize the 
                                       Missouri Department of Revenue and its designated financial agent to initiate Electronic Funds Transfer (EFT) payments from the designated 
                                       account for payments of state taxes owed. This authorization is to remain in full force and effect until I notify the Department to terminate the 
                                       authorization. To terminate this authorization I must contact the Taxation Division at phone number listed on this form no later than seven 
                                       business days prior to the payment date. I also authorize the financial institutions involved in the processing of the electronic payments to receive 
                                       confidential information necessary to answer inquiries and resolve issues related to the payments. I understand that a convenience fee will 
                                       be charged for each EFT transaction and current fees can be found at the website provided. I understand in the event that my bank returns a 
                  Signature            payment due to insufficient funds an additional charge will be electronically debited from my account by the processor (JetPay) in addition to 
                                       whatever charges my bank may assess. 
                                       Signature                                                                            Date (MM/DD/YYYY) 
                                                                                                                            ___ ___ /___ ___ /___ ___ ___ ___

                                                                                                                                   Form 4338 (Revised 05-2023)
Mail To:                               Taxation Division                    Phone:  (573) 751-7200                           
                                       P.O. Box 1002                        Fax:  (573) 522-1271                    *17356010001*
                                       Jefferson City, MO 65105-1002        E-mail:  paymentplan@dor.mo.gov                  17356010001