Page 362 - Individual Forms & Instructions Guide

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The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.
The direct debit from your checking account won’t • You live with and share household expenses with your
! be approved unless you (and your spouse if filing spouse. Even if only one spouse is liable for the taxes
CAUTION a joint return) sign Form 9465. owed, the total household income and expenses are
Sample Check—Lines 13a and 13b relevant in determining the liable spouse’s ability to pay
the taxes owed.
Paul Maple 1234 • You live in a community property state. In a community
Roberta Maple SAMPLE
123 Pear Lane 15-0000/0000 property state, the income of a non-liable spouse may be
Anyplace, VA 20000 factored into the other spouse’s ability to pay the taxes
owed.
PAY TO THE
ORDER OF $ You should complete lines 21 and 22 whether your filing
Routing Account
number number DOLLARS status is married filing jointly or married filing separately.
(line 13a) (line 13b)
ANYPLACE BANK
Anyplace, VA 20000 Don’t include
the check number. Privacy Act and Paperwork Reduction Act Notice.
Our legal right to ask for the information on this form is
For
sections 6001, 6011, 6012(a), 6109, and 6159 and their
:250250025
| | :202020"'86". 1234
The routing and account numbers may be in regulations. We will use the information to process your
request for an installment agreement. The reason we
TIP different places on your check. need your name and social security number is to secure
proper identification. We require this information to gain
Line 13c. Low-income taxpayers who are unable to access to the tax information in our files and properly
make electronic payments through a DDIA by providing respond to your request. You aren’t required to request an
their information on lines 13a and 13b are eligible to installment agreement. If you do request an installment
receive reimbursement of their installment agreement agreement, you’re required to provide the information
user fees. If you’re a low-income taxpayer and you requested on this form. Failure to provide this information
checked the box in line 13c, your installment agreement may prevent processing your request; providing false
user fee will be reimbursed upon completion of your information may subject you to fines or penalties.
installment agreement. See User fee waivers and You aren’t required to provide the information
reimbursements, earlier, for more information. requested on a form that is subject to the Paperwork
If you don’t check the box in line 13c (and don’t provide Reduction Act unless the form displays a valid OMB
the information on lines 13a and 13b), you’re indicating control number. Books or records relating to a form or its
that you’re able but choosing not to make electronic instructions must be retained as long as their contents
payments by establishing a DDIA. As such, your user fee may become material in the administration of any Internal
is not eligible for reimbursement upon completion of your Revenue law. Generally, tax returns and return
installment agreement. information are confidential, as required by section 6103.
Line 14 However, we may give this information to the Department
of Justice for civil and criminal litigation, and to cities,
If you want to make your payments by payroll deduction, states, the District of Columbia, and U.S. commonwealths
check the box on line 14 and attach a completed and and possessions to carry out their tax laws. We may also
signed Form 2159. Ask your employer to complete and disclose this information to other countries under a tax
sign the employer’s portion of Form 2159. treaty, to federal and state agencies to enforce federal
If you choose to make your payments by payroll nontax criminal laws, or to federal law enforcement and
intelligence agencies to combat terrorism.
! deduction, you won’t be able to file Form 9465
CAUTION electronically. The average time and expenses required to complete
and file this form will vary depending on individual
Part II circumstances. For the estimated averages, see the
If you have defaulted on an installment agreement within instructions for your income tax return.
the last 12 months, the amount you owe is greater than If you have suggestions for making this form simpler,
$25,000 but not more than $50,000, and the amount on we would be happy to hear from you. See the instructions
line 11a (line 11b, if applicable) is less than line 10, for your income tax return.
complete Part II on page 2 of Form 9465.
Lines 21 and 22
Complete lines 21 and 22 relating to income earned by
your spouse if you are married and meet either of the
following conditions.

-6- Instructions for Form 9465 (Rev. 10-2020)