Payment Arrangement Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
My account is in bankruptcy
Yes
No
Bankruptcy Case Number
Employer Name
*
Employer Email
*
Bank Name
*
Bank Phone Number
*
Please attach any relevant documentation associated with your employer or bank. (Paystub Bank Account, etc.)
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Formats accepted: pdf, doc, docx
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of
Tax Type & Bill Numbers
*
Please indicate the desired payment arrangements from the choices below:
*
Payment of half the amount due, with remainder being paid in five equal payments over the course of no longer than five months.
Other
If "other," please detail your desired payment arrangment.
Eligibility Requirements
Payment arrangements are not active until authorized, and the taxpayer is notified after submission of this application.
Payment arrangements do not stop the yearly submission of the taxpayers account to the state for tax withholding.
If a payment is missed after 30 days the arrangements will be considered broken and immediate collection action will be issued.
Should the taxpayer have broken any prior payment arrangement no new arrangements will be made until the missed payments have been paid in full.
Do you agree to the above eligibility requirements
*
Yes, I agree.
Submit
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