Fillable Printable Installment Agreement Request - Georgia
Fillable Printable Installment Agreement Request - Georgia
Installment Agreement Request - Georgia
Installment Agreement Request
PLEASE READ:
Instructions for Form GA- 9465, Installment Agreement Request
General Instructions
Purpose of Form
Use Form GA-9465 to request a monthly installment plan if
you cannot pay the full amount you owe shown on your tax
return (or on a notice we sent you). Generally, you can have
up to 36 months to pay. Before requesting an installment
agreement, you should consider other less costly alternatives,
such as getting a bank loan or using available credit on a
credit card.
Do not file this form if you are in bankruptcy or have a pending
offer-in-compromise. If your tax liability has been assigned to
a private collection agency, contact that particular agency for
payment plan options.
How the Installment Agreement Works
We will usually let you know within 30 days after we receive
your request whether it is approved or denied. If we approve
your request, you will receive a notice detailing the terms
of the agreement. Please note that an additional $50
administration fee will be added to the first payment due.
You may qualify to pay a reduced fee of $25 if your income is
less than $22,050.
You will also be charged interest and may be charged a late
payment penalty on any tax not paid by its due date, even if
your request to pay in installments is granted. Interest and
any applicable penalties will be charged until the balance is
paid in full. To limit interest and penalty charges, file your
return on time and pay as much of the tax as possible with
your return (or notice). All payments received will be applied
to your account in the best interests of the State of Georgia.
Also, any refund due you in a future tax period may be applied
against the amount you owe. If there remains a balance after
the refund is applied, you are still required to make your
regular monthly payments until the liability is paid in full. If the
offset of your refund pays the assessment in full, we will
cancel the automatic debit from your account. Any
overpayment of your account will be refunded to you.
Payment Method
The Department of Revenue accepts payment by electronic
funds withdrawal from your checking or savings account at a
bank or other financial institution.
Modification of an Installment Agreement
After an installment agreement is approved, you may submit a
request to modify the original agreement. If the modification
is approved, the Department will charge you a$50
administration fee.
You may qualify to pay a reduced
administrative fee of $25 if your income is less than $22,050.
You must comply with the existingagreement while the
Department considers your request to modify the agreement.
Termination of an Installment Agreement
If you do not make your payments on time or do not pay any
balance due on a return you file later, you will be in default on
your agreement and we may take enforcement actions, such
asthe filing of a state tax execution or a levy or garnishment
action, to collect the entire amount you owe.
•
DO NOT submit this form if you are currently in bankruptcy, have unfiled state tax returns that are past due, have a pending
•
DO try and submit this form electronically by visiting the Department’s Georgia TaxCenter at https://gtc.dor.ga.gov.
•
DO enter the Letter ID in Line 1 if you received a notice from the Department showing an amount due.
Please note that you will not be able to submit an installment payment agreement request via the Georgia Tax Center if you
have an active protest or appeal, are subject to a Department enforcement action, are in bankruptcy, have an accepted offer
in compromise, or already have an active payment plan with the Department.
offer in compromise with the Department, or your state tax liability has been assigned to a private collection agency.
If your liability has been assigned to a private collection agency, contact that agency.
If a tax execution has already been recorded prior to the
approval of the agreement, the Department will not initiate
enforcement action against you to collect the outstanding tax
debt. Upon default of the installment agreement, the Depart-
ment may initiate all appropriate enforced collection activity.
The issuance of a tax execution will result in the imposi-
tion of an additional 20% collection fee that will be added
to the tax liability.
By approving your request, we agree to let you pay the tax you
owe in monthly installments instead of immediately paying the
amount in full. In return, you agree to make your monthly
payments on time. You also agree to meet all your future tax
liabilities.For example,this meansthat you must have
enough withholding or estimated tax payments so that your
income tax liability for future years is paid in full when you
timely file your return. Your request for an installment agree-
ment will be denied if all required tax returns have not been
filed.
Check tax type and enter the related tax identification number and tax periods at issue:
1.
L
2.
4.
Enter the total amount you owe as shown on your tax return or notice: _______________________
5.
Enter the total number of months subject to the installment payment agreement, not to exceed 36 months:
6.
Enter the amount you will pay each month:
Enter the day (1
st
to 28
th
) your monthly payment will be debited from your bank account:
8.
All payments must be made by electronic funds withdrawal from your checking account. Complete the following information:
Name of Financial InstitutionAddress
b.
Routing Number:
a.
Checking Savings
7.
Account Number:
Georgia Department of Revenue
Installment Agreement Request
Form
GA-9465
(Rev. 2/2013)
Page 1
Taxpayer’s First Name
Middle Initial Last Name
Social Security Number
If a joint liability, Spouse’s First Name
Middle Initial Last Name Social Security Number
Business Name
(use if business is requesting installment payment agreement)
Federal Employer Identification No.
Taxpayer’s Mailing Address City State ZIP
Phone Number
3.
Your SignatureDate
Spouse’s Signature(if a joint return, both must sign)
Date
9.
City State ZIP
Enter tax periods at issue:
_ _ _ _ _ _ _ _ _ _
Withholding Tax
Other
TAX ID:
Individual Income Tax
SSN:
FEIN:
Corporate
Income Tax
Sales and Use Tax
STN:
IFTA Fuel Tax
IFTA: GA
WTN:
-
-
-
-
_ _ _ _ _ _ _ _ _ _
If you received a notice showing an amount due, please enter the Letter ID number listed on the notice (if available):
I hereby waive all rights of any additional notice or appeal concerning the assessment and collection of any part or all of the tax liability to
be paid by means of this installment payment agreement request. I specificallywaive the 30 dayperiod to contest any notice of proposed
assessment issued under O.C.G.A. § 48-2-46 and the right to appeal anyfinal assessment notice issued under O.C.G.A § 48-2-47.
I authorize the Georgia Department of Revenue and its designated financial agent to initiate a monthly ACH electronic funds withdrawal entry to the
financial institution account indicated above for payments of the state taxes owed and the financial institution to debit the entry to this account. I also
authorize the financial institutions involved in the processing of electronic payments of taxes to receive confidential information necessary to answer
inquires and resolve issues related to those payments. By mutual agreement, it is understood that any tax refund, state or federal, will be applied
through offset to the liability included in this payment agreement request until such is fully paid and satisfied. Your signature acknowledges that
you have waived all rights of any additional notice, refund, or appeal concerning the assessment and collection of any part or all of the
tax liability to be paid by means of this installment payment agreement request.
MAIL TO:
Georgia Department of Revenue
Processing Center
PO Box 740396
Atlanta, GA 30374-0396
Provide all requested information. If you are making this
request for a joint tax return, show the names and social
security numbers (SSNs) in the same order as on your tax
return. If you are making this request for a business, show
the name of the person responsible for paying any sales or
withholding taxes and the related social security numbers on
line 3.
Line 1
If you received a notice from the Department showing an
amount due, enter the Letter ID listed on the notice. Doing so
will help the Department process your request.
Line 2
Line 4
Enter the total amount you owe as shown on your tax return
or notice.
Line 5
Enter the total number of months subject to theinstallment
payment agreement not to exceed 36 months.
Line 6
Enter the amount you can pay each month.Interest and
penalties will continue to accrue until you pay in full.
Line 7
Enter the day your monthly payment will be debited from your
bank account (1st to the 28th).
Line 8
Line 8a
The routing number must be nine digits. The first two digits of
the routing number must be 01 through 12 or 21 through 32.
Use a check to verify the routing number. On the sample
check on this page, the routing number is 250250025. But if
your check is payable through a financial institution do not use
the routing number on that check. Instead, contact your
financial institution for the correct routing number. Do not
use the routing number indicated on your deposit slip.
Line 8b
The account number can be up to 17 characters (both
numbers and letters). Include hyphens but omit spaces and
special symbols. Enter the number from left to right and leave
any unused boxes blank. On the sample check below, the
account number is 20202086. Do notincludethe check
number.
Line 9
You (or in the case of a business, the person responsible for
remitting payments) must sign the statement. This signature
authorizes the Georgia Department of Revenue to use the
information on this form to make monthly withdrawals from the
account listed in Line 8. This authorization remains in force
until the Department receives written notification from you.
Your signature also acknowledges that you have waived all
rights of any additional notice, refund, or appeal concerning
the assessment and collection of any part or all of the tax
liability to be paid by means of this installment agreement
request.
Specific Instructions
To avoid processing delays,
Form
GA-9465
(Rev. 2/2013)
Page 2
•
V
O
I
D
In order to pay by electronic funds withdrawal from your check-
ing account at a bank or other financial institution (such as
mutual fund, brokerage firm, or credit union), you must fill in all
information requested in line 8. Check with your financial
institution to make sure that an electronic funds withdrawal is
allowed and to get the correct routing and account numbers.
Attach a blank check to your installment payment request and
mark “VOID” across the front.
(line 8a)
(line 8b)
Check the box to identify the tax type for the installment
payment agreement request and the corresponding tax identifi-
cation number.
