INSTALLMENT AGREEMENT REQUEST LETTER

IRS FORM 9465 SUBMISSION COVER LETTER

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TAXPAYER INFORMATION

Taxpayer Name: [FULL LEGAL NAME]

Social Security Number / EIN: [SSN/EIN]

Spouse Name (if joint liability): [SPOUSE NAME]

Spouse SSN (if joint liability): [SPOUSE SSN]

Current Address:
[STREET ADDRESS]
[CITY, STATE ZIP]

Daytime Telephone: [PHONE NUMBER]

Best Time to Call: [TIME]

Email Address: [EMAIL]

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COVER LETTER

[DATE]

Internal Revenue Service
[ADDRESS FROM YOUR NOTICE]

Re: Request for Installment Agreement
Taxpayer(s): [NAME(S)]
Social Security Number(s): [SSN(S)]
Tax Year(s): [TAX YEARS]
Total Balance Due: $[AMOUNT]
IRS Notice Number: [NOTICE NUMBER, IF APPLICABLE]

Dear Sir or Madam:

I am writing to request an installment agreement pursuant to IRC § 6159 for the payment of outstanding federal tax liabilities. I am unable to pay the full amount due at this time, but I am committed to satisfying my tax obligations through monthly installment payments.

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SECTION 1: TAX LIABILITY SUMMARY

Tax Year	Tax Type	Amount Owed	Penalties	Interest	Total
[YEAR]	[TYPE]	$[AMOUNT]	$[AMOUNT]	$[AMOUNT]	$[TOTAL]
[YEAR]	[TYPE]	$[AMOUNT]	$[AMOUNT]	$[AMOUNT]	$[TOTAL]
[YEAR]	[TYPE]	$[AMOUNT]	$[AMOUNT]	$[AMOUNT]	$[TOTAL]
TOTAL					$[GRAND TOTAL]

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SECTION 2: INSTALLMENT AGREEMENT TYPE REQUESTED

Select the type of installment agreement being requested:

☐ Guaranteed Installment Agreement (IRC § 6159(c))
- Total tax liability is $10,000 or less (excluding interest and penalties)
- All returns filed on time for the past 5 years
- No installment agreements in the past 5 years
- Agreement to pay within 3 years or by collection statute expiration

☐ Streamlined Installment Agreement ($50,000 or less)
- Total balance due is $50,000 or less
- Can pay within 72 months or by collection statute expiration
- No financial statement required
- Direct Debit (DDIA) may be required

☐ Non-Streamlined Installment Agreement (Over $50,000)
- Total balance due exceeds $50,000
- Form 433-F or 433-A required
- Agreement based on Reasonable Collection Potential
- May require additional documentation

☐ Partial Payment Installment Agreement (PPIA)
- Monthly payment is less than minimum required
- Full payment not feasible within collection period
- Form 433-A/B required
- Subject to periodic financial review

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SECTION 3: PROPOSED PAYMENT TERMS

Proposed Monthly Payment: $[MONTHLY AMOUNT]

Proposed Payment Date: [DAY OF MONTH] of each month

First Payment Date: [DATE]

Payment Method:

☐ Direct Debit from Bank Account (DDIA) - Reduced user fee
- Bank Name: [BANK NAME]
- Routing Number: [ROUTING NUMBER]
- Account Number: [ACCOUNT NUMBER]
- Account Type: ☐ Checking ☐ Savings

☐ Payroll Deduction
- Employer Name: [EMPLOYER]
- Employer Address: [ADDRESS]
- Employer Phone: [PHONE]

☐ Electronic Federal Tax Payment System (EFTPS)

☐ Check or Money Order

☐ IRS Direct Pay (online)

☐ Credit/Debit Card

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SECTION 4: USER FEE INFORMATION

Installment Agreement User Fees (Effective July 1, 2024):

Setup Method	Standard Fee	Low-Income Fee
Online Payment Agreement (OPA) - Direct Debit	$22	Waived
Online Payment Agreement (OPA) - Other	$69	Waived
Phone/Mail/In-person - Direct Debit	$107	Waived
Phone/Mail/In-person - Other	$178	Waived
Reinstatement/Restructure - OPA	$10	N/A

☐ Low-Income Fee Waiver Requested
- Taxpayer's adjusted gross income is at or below 250% of federal poverty guidelines
- Supporting documentation: [LIST]

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SECTION 5: FINANCIAL INFORMATION SUMMARY

Monthly Income:

Source	Amount
Wages/Salary (Taxpayer)	$[AMOUNT]
Wages/Salary (Spouse)	$[AMOUNT]
Self-Employment Income	$[AMOUNT]
Social Security	$[AMOUNT]
Pension/Retirement	$[AMOUNT]
Rental Income	$[AMOUNT]
Other Income	$[AMOUNT]
Total Monthly Income	$[TOTAL]

Monthly Necessary Living Expenses:

Expense Category	Amount	IRS Standard (if applicable)
Housing (rent/mortgage)	$[AMOUNT]	$[STANDARD]
Utilities	$[AMOUNT]	$[STANDARD]
Food/Groceries	$[AMOUNT]	$[STANDARD]
Transportation	$[AMOUNT]	$[STANDARD]
Health Insurance	$[AMOUNT]	Actual
Out-of-Pocket Medical	$[AMOUNT]	Actual
Court-Ordered Payments	$[AMOUNT]	Actual
Child Care	$[AMOUNT]	Actual
Life Insurance	$[AMOUNT]	[AMOUNT]
Other Necessary Expenses	$[AMOUNT]	[DESCRIBE]
Total Monthly Expenses	$[TOTAL]

Monthly Disposable Income: $[INCOME - EXPENSES]

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SECTION 6: REASON FOR INABILITY TO PAY IN FULL

[PROVIDE A DETAILED EXPLANATION OF WHY YOU CANNOT PAY THE FULL AMOUNT DUE AT THIS TIME. INCLUDE RELEVANT CIRCUMSTANCES SUCH AS:]

☐ Job loss or reduced income
☐ Medical expenses or illness
☐ Unexpected expenses
☐ Family circumstances (divorce, death, etc.)
☐ Business downturn
☐ Other: [EXPLAIN]

Narrative:
[DETAILED EXPLANATION]

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SECTION 7: ASSETS SUMMARY

Asset Type	Description	Fair Market Value	Loan Balance	Equity
Primary Residence	[ADDRESS]	$[VALUE]	$[BALANCE]	$[EQUITY]
Other Real Estate	[DESCRIPTION]	$[VALUE]	$[BALANCE]	$[EQUITY]
Vehicles	[YEAR/MAKE/MODEL]	$[VALUE]	$[BALANCE]	$[EQUITY]
Bank Accounts	[INSTITUTIONS]	$[VALUE]	N/A	$[VALUE]
Investments	[DESCRIPTION]	$[VALUE]	N/A	$[VALUE]
Retirement Accounts	[TYPE]	$[VALUE]	N/A	$[VALUE]
Other Assets	[DESCRIPTION]	$[VALUE]	$[BALANCE]	$[EQUITY]
Total		$[TOTAL]	$[TOTAL]	$[TOTAL]

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SECTION 8: ENCLOSURES CHECKLIST

Required for All Requests:
☐ Completed Form 9465, Installment Agreement Request
☐ Copy of most recent IRS notice
☐ Copy of filed tax returns for years included in the agreement

Additional Requirements for Balances Over $50,000:
☐ Form 433-F, Collection Information Statement (individuals)
☐ Form 433-A, Collection Information Statement for Wage Earners and Self-Employed
☐ Form 433-B, Collection Information Statement for Businesses

Supporting Documentation:
☐ Proof of income (pay stubs for past 3 months)
☐ Bank statements (past 3 months)
☐ Proof of necessary expenses
☐ Asset valuations
☐ Voided check (if requesting Direct Debit)
☐ Form 2848, Power of Attorney (if represented)
☐ Other: [DESCRIBE]

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SECTION 9: TAXPAYER CERTIFICATIONS

I hereby certify that:

☐ All federal tax returns required to be filed have been filed

☐ All information provided in this request is true and accurate

☐ I understand that penalties and interest will continue to accrue until the balance is paid in full

☐ I agree to remain in compliance with all future tax filing and payment requirements

☐ I understand that failure to comply with the terms of the installment agreement may result in default and enforcement action

☐ I understand that tax refunds may be applied to the outstanding balance while the agreement is in effect

☐ I authorize the IRS to contact my employer regarding payroll deduction (if elected)

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SECTION 10: REPRESENTATIVE INFORMATION (IF APPLICABLE)

Representative Name: [NAME]

Firm Name: [FIRM]

Address:
[ADDRESS]

Telephone: [PHONE]

Fax: [FAX]

Email: [EMAIL]

CAF Number: [CAF NUMBER]

☐ Form 2848, Power of Attorney and Declaration of Representative is attached

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SECTION 11: ONLINE PAYMENT AGREEMENT OPTION

Faster Processing Available Online:

For balances of $50,000 or less, you may apply online at:
www.irs.gov/opa

Benefits of Online Application:
- Reduced user fees
- Immediate confirmation
- No forms to mail
- 24/7 availability

Online Application Requirements:
- Individual taxpayer (not business)
- All required returns filed
- Balance due of $50,000 or less
- Ability to pay within 72 months

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MAILING INSTRUCTIONS

For Form 9465 Filed Without a Return:

Mail to the address on your most recent IRS notice, or:

Internal Revenue Service
[APPROPRIATE IRS SERVICE CENTER ADDRESS BASED ON STATE]

For Form 9465 Filed With a Return:

Attach Form 9465 to the front of your tax return and mail to the address specified in the return instructions.

Certified Mail Recommended
Certified Mail Number: ______________________
Date Mailed: ______________________

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IMPORTANT NOTICES

1. Levy Protection: Once an installment agreement is approved, the IRS generally will not levy or seize property while the agreement is in effect.

2. Federal Tax Lien: The IRS may still file a Notice of Federal Tax Lien even with an approved installment agreement.

3. Interest and Penalties: Interest and failure-to-pay penalties continue to accrue during the installment agreement.

4. Refund Offset: Any tax refunds will be applied to the balance due.

5. Future Compliance: All future tax returns must be filed on time and all taxes paid when due.

6. Default: Missing a payment or failing to file a return or pay current taxes will result in default.

7. Annual Review: Partial payment installment agreements are subject to financial review at least every two years.

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Thank you for your consideration of this installment agreement request. Please contact the undersigned with any questions or if additional information is needed.

Respectfully submitted,

Taxpayer Signature: ___________________________________

Printed Name: [TAXPAYER NAME]

Date: [DATE]

Spouse Signature (if joint): ___________________________________

Printed Name: [SPOUSE NAME]

Date: [DATE]

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This template is provided for informational purposes and should be reviewed by qualified tax counsel before submission to the IRS.