Fillable Printable Installment Plan Agreement

Installment Plan Agreement

INSTALLMENT PLAN AGREEMENT

Log No. _________________

Name _____________________________________ Account Balance __________

DBA ______________________________________ Amount of Offer ___________

Account No. ________________________________ Date ___________________

I promise to satisfy the amount offered, by paying the sum of $ _________________ .

I understand that the initial payment of $ ____________ is due on ______________ .

Subsequent installments in the amount of $ _____________ will be paid on the same

day of each succeeding ____________________________ until the entire amount

has been paid in full.

I further understand that failure to pay as promised will result in termination of the Offer

in Compromise, and monies paid to the Employment Development Department will be

applied against the total liability.

I certify that I have read and fully understand the conditions and terms of this agreement

as stated on the Installment Plan Information Sheet.

By ____________________ Title _________________ Date _________________

(over)

DE 999D Rev. 1 (1-15) (INTERNET) Page 1 of 2

INSTALLMENT PLAN INFORMATION SHEET

INTRODUCTION

The Offer in Compromise program allows for installment payments under an

agreement not to exceed five years.

ABILITY TO PAY

An installment plan will be considered ONLY if you demonstrate the inability to

pay the compromised amount in full.

REQUIREMENT OF PARTIAL PAYMENT

Your offer must not exceed a five year period. Payment must be submitted in the

form of cash (do not send cash through the mail), cashier’s check, or money

order.

All payments made with this offer are submitted voluntarily. In the event an offer

is not accepted, the amount will either be applied to the liability or refunded at the

discretion of the employer or individual submitting the offer.

When entering into a partial payment agreement to satisfy the amount offered

and the applicant defaults, the agreement will be rescinded. All compromised

liabilities and liens will be reestablished without regard to the statute of

limitations. All monies paid on the compromised amount will be applied to the

reestablished liability.

DE 999D Rev. 1 (1-15) (INTERNET) Page 2 of 2