Fillable Printable Sample Form for Installment Agreement
Fillable Printable Sample Form for Installment Agreement
Sample Form for Installment Agreement
IncomeTaxBureau
PostOfficeBox22805
Jackson,MS39225-2805
Phone:(601)923-7040
Fax:(601)923-7039
4.
3.
Ifthisaddressisnewsinceyoufiledyourlasttaxreturn,checkhere:
Instructions
Spousesocialsecuritynumber
Yoursocialsecuritynumber
Apt.number
Ifjointreturn,spouse'sfirstnameandinitial
Extension
Lastname
Lastname
City,Town,orPostOffice,State,andZIPCode.
Yourcurrentaddress(numberandstreet).IfyouhaveaP.O.boxandnohomedelivery,enteryourboxnumber.
1.
2.
Form71-661-10-8-1-000(Rev.05/10)
()
Youremployer'sname:
PhoneNumber
5.
Address
City,State,ZipCode
Yourfirstnameandinitial
Nameofyourbankorotherfinancialinstitution:
Address
City,State,ZipCode
Caution:Donotfilethisformifyouarecurrentlymakingpaymentsonaninstallmentagreement.Ifyouarein
bankruptcy,seeinstructions.
BestTimetoCall
7.
8.
9.Entertheamountdueeachmonth.Interestwillcontinueuntilyoupayinfull.
Enterthetotalamountyouowe(asshownonyourreturn).
6.
7.
8.
9.
Entertheamountofanypaymentyouaremakingwithyourtaxreturn(Seeinstructions).
Roundtowholedollars.
6.
Mississippi
InstallmentAgreement
MustBeAttachedToFrontOfReturn
DuplexandPhotocopiesNOTAcceptable
Enterthetaxyearforwhichyouaremakingthisrequest.
Aninstallmentagreementisavailabletotaxpayersthathaveataxliabilityofatleast$75.Inordertoqualifyforthe
installmentagreement,thereturnmustbefiledonorbeforetheduedate,oranyextensionsallowed,andthis
requestformmustbesubmittedwiththereturn.You(andyourspouseifajointreturn)musthavefiledallrequired
incometaxreturnsandpaidalltaxesdueforthepastfiveyears.Youalsocannothavepreviouslyenteredintoan
installmentagreementduringthepastfiveyears.
Therearetwo(2)typesofinstallmentagreementsfortaxpayersthathaveataxliability:
(1)Taxliabilityof$75butnomorethan$3,000-Theinstallmentagreementallowsyoutopaytheamount
dueintwelveequalinstallments.
(2)Taxliabilityexceeding$3,000andaninstallmentagreementwiththeInternalRevenueService(IRS)
forthesametaxyear-Theinstallmentagreementallowsyoutopaytheamountduewithinuptosixty
uptosixtymonths.MustattachacopyoftheapprovedinstallmentagreementnotificationfromtheIRS.
Theagreementmaybeterminatedifanyinstallmentpaymentisnotmadetimely.Itmayalsobeterminatedifyou
donotpayanyothertaxliabilitywhentheliabilityisdue.
Interestofonepercent(1%)permonthcontinuestoaccrueduringtheinstallmentagreementperiod.Youwillneed
tocontactourofficefortheremainingbalanceontheaccountpriortothelastpaymenttoensuretheinterestispaid
correctly.
Ifyouhaveapendingbankruptcycase,youmaybebarredbyfederallawfromparticipationinaninstallment
agreement;pleasecontactourofficeformoredetails.Additionally,ifyoufilebankruptcyduringtheinstallment
period,youmustnotifyourBankruptcySectionimmediatelyat601-923-7393;duetotheautomaticstayprovisions
oftheU.S.BankruptcyCodetheinstallmentagreementmaybevoidatthetimeyoufileyourbankruptcycase.
