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                                                                                                      Department Use Only
                                       Form
                                                   Missouri Department of Revenue                     (MM/DD/YY)
                                       4338        Individual Income Tax Payment Installment Request

Social Security Number                                                                    Spouse’s Social Security Number

                                                 -       -                                             -                 -
Taxpayer Name                                                                             Spouse’s Name

In the event that you are unable to pay the entire income tax amount due in full, a tax payment installment agreement may be requested online at 
www.dor.mo.gov/cacs/ 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 www.dor.mo.gov or you can attach your return(s) to this request.
Payment agreement, if approved, will be for no longer than a 24-month term and a down payment may be required. We encourage you to make your 
payments as large as possible to reduce the interest you must pay. 
Do not file this form if you are currently making payments on an installment agreement.

                                       Address                                            City                             State ZIP Code

                                       Daytime Telephone Number             Tax Years                 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 01-2019)

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