Fillable Printable Installment Agreement Request

Installment Agreement Request

DE 927B Rev. 1 (4-12) (INTERNET) P.O. BOX 989150, MIC 92F • WEST SACRAMENTO, CA 95798-9150 CU

Installment Agreement Request

On behalf of the business identified below, as an individual owner, partner or representative of the corporation, I request that

the Employment Development Department (EDD) accept an installment agreement in order to liquidate debts due. The

following is submitted, along with a Good Faith payment, in consideration of this request:

Employer Account Number

Owner Name Social Security No. or Corporate ID No.

Business Name

Address (number and street)

City, State, and ZIP Code

Mailing Address (if different from above)

City, State, and ZIP Code

If you are an individual owner, partner, or a person assessed under

Section 1735 of the CUIC and no longer in business, complete the following:

Name of Bank or Other Financial Institution

Current Employer’s Name

Address Address

City, State, and ZIP Code

Proposed payment amount:

Frequency (check one): Monthly Bi-weekly Weekly

Good Faith payment enclosed:

I understand:

 The EDD has the right to refuse this installment agreement request.

 Installment agreements exceeding one year in length require full financial disclosure and documentation.

 Additional interest accrues daily on the unpaid balance at the rate prescribed by law.

 All missing and delinquent reports must be filed in order to request a payment arrangement.

 The EDD will file a Notice of State Tax Lien for outstanding liabilities.

 I will be subject to an offset of any state refund due to me, including State Income Tax refunds and Lottery winnings,

as well as any Federal Income Tax refund due to me by the U.S. Department of the Treasury, as prescribed by law.

 The EDD may assess responsible individuals for any unpaid corporate, limited liability company, or limited liability

partnership liability.

 Failure to adhere to the installment agreement and/or incurring any additional liability may be considered a default,

and involuntary collection action may be taken without further notice to me or to the organization listed above.

Signature (Owner/Responsible Party) Title Date

( ) - ( ) -

Print Name Phone Number Alternate Phone Number

( ) - ( ) -

Contact Person (please print) Phone Number Alternate Phone Number

DE 927B Rev. 1 (4-12) (INTERNET) P.O. BOX 989150, MIC 92F • WEST SACRAMENTO, CA 95798-9150 CU

INSTALLMENT AGREEMENT REQUEST (DE 927B) INSTRUCTIONS

Complete all requested information. Write “N/A” (not applicable) in those areas that do not apply to

your business. If the form is incomplete or unsigned, we will not be able to consider your request for

an installment agreement.

If you are an individual owner, partner, or responsible person assessed under Section 1735 of the

California Unemployment Insurance Code (CUIC) and the business is no longer active, complete the

section that requests information about your current employer.

If the installment agreement you are requesting exceeds one year in length, you must complete a

financial statement and submit the required documents for substantiation. The forms Financial

Statement (DE 926B) and/or the Financial Statement for Businesses (DE 926C) are available, but

any recent financial statement which has substantially the same data is acceptable.

For account balance information, please refer to the most recent Statement of Account (DE 2176)

or call the Taxpayer Assistance Center at 888-745-3886.

A Good Faith payment is required when requesting an installment agreement.

All missing and delinquent reports must be filed before requesting an installment agreement.

An approved installment agreement does not prevent an offset of any State or Federal Income Tax

refund; however, it may prevent involuntary collection actions. Any offset amount received will not

affect your scheduled payments but may reduce the length of the agreement.

An approved installment agreement does not prevent a lien from being filed. The EDD will file a

Notice of State Tax Lien (DE 2181) for outstanding liabilities.

Send Good Faith payment and completed DE 927B to:

EDD

P.O. Box 989150, MIC 92F

West Sacramento, CA 95798-9150

To ensure proper posting of funds to your account, please make sure your employer account number

is on your check or money order.

More information on installment agreements can be found on the Information Sheet: Installment

Agreement (DE 631P).

Forms and publications are available on the EDD’s website at

www.edd.ca.gov/Payroll_Taxes/Forms_and_Publications.htm. To request forms or publications

be mailed or faxed to you, please contact the Taxpayer Assistance Center at 888-745-3886.