Print Clear State of Georgia
(Revised 6/2009) Department of Revenue
INSTALLMENT PAYMENT PLAN APPLICATION
READ THIS INFORMATION FIRST: Everyone must complete Steps 1, 3, 4, and 5. Complete Step 2 only if you are a business
requesting an installment payment plan for a sales and use tax liability. Note: You must complete Form CDLO-14B Statement
of Financial Affairs – Individual, or Form CDLO-14C, Statement of Financial Affairs – Business if the requested payment plan
period exceeds twelve months.
PLEASE REMEMBER TO INCLUDE VOIDED
John Q.Sample 123456
CHECK WITH APPLICATION SUBMISSION.
123456 987654321111 SEE INSTRUCTIONS ON PAGE 4, STEP 4 FOR FURTHER DETAILS.
Step 1: Personal Information (include your spouse, if applicable)
1. Your social security number Spouse’s social security number
Your last name Spouse’s last name (if different)
Your first name and middle initial Your spouse’s first name and middle initial
Mailing address City State ZIP E-mail address
Your home phone number Your work phone number Spouse’s work phone number
( ) ( ) ( )
Check here if this address has changed since the filing of your last tax return.
Step 2: Identify your business and the person responsible for remitting payments (business only)
2. Federal Employer Identification Number (FEIN) State Taxpayer Identification Number Sales Tax Account Number
Mailing Address City State ZIP
Person responsible for remitting payments Phone
Step 3: Figure your monthly payment agreement amount
3. Have all your tax returns been filed? (For this agreement to be considered all returns must be filed) Yes No
4. Identify the tax type covered by this agreement (choose one): Individual income tax Sales and use tax
5. Identify the tax periods covered by this agreement:
6. Will this agreement consist of twelve monthly payments? Yes. No. If not, how many months? ________
Note: Most Installment agreements for Individual Income Tax will be approved for a period of up to 12 months and in some cases
18 months with approval of the Statement of Financial Condition for Individuals (Form CD-LO14B).
7. If this is a sales and use tax agreement, please write the date you want your payments to be due each month (1st to 28th
day) Note: Income tax plan payments will be automatically debited on the tenth of each month.
8. Total amount of your unpaid tax liability 8. $____________
9. Enter the amount of your down payment 9. $ ____________
Payment must equal or be greater than 1/3 of sales or use tax liability. No down payment is required for an individual income tax liability.
10. Write the amount of your requested monthly payment 10. $ ___________
Form GA-9465 (Rev. 6/2009) Page 2
Step 4: Provide your financial institution’s name and account information and attach a voided check.
11. Financial institution’s name
Mailing address City State ZIP
Names on the account (list all names)
Routing number Checking Savings
Find your routing number at the bottom of your check (for checking accounts) or contact
your financial institution for the routing number (for savings accounts).
Step 5: Signature authorization for taxpayer, authorized officer, or partner
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 my state taxes owed and the
financial institution to debit the entry to this account. This authorization is to remain in full force and effect until I notify the
Georgia Department of Revenue to terminate the authorization. To revoke payment, I must contact the Georgia
Department of Revenue at (404) 417-6486 no later than the 3rd day of the month prior to the payment date. I also
authorize the financial institutions involved in the processing of electronic payments of taxes to receive confidential
information necessary to answer inquiries and resolve issues related to those payments.
Your signature Date Spouse’s signature. If a joint return, both must sign. Date
SPOUSE SIGNS ONLY IF INCOME TAX PAYMENT PLAN
Who should file this form? the offset of your refund pays the assessment in full, we will cancel
You should file Form GA-9465 Installment Payment Plan Request the automatic debit from your account. Any overpayment of your
if you have either a sales and use tax or individual income tax account will be automatically refunded to you.
delinquency that you cannot pay in full because of a financial When will my installment payment plan request be
Do not file this form if you are in bankruptcy, have a pending offer-
in-compromise, or if your tax liability has been assigned to a private Approval of your request for an installment payment plan will depend
collection agency. upon the completeness of the information you provide on this form. If
additional information is needed to process your request, we will
What is an installment payment plan? contact you.
A installment payment plan is an agreement between you and the In addition to providing all requested information, you must have filed
Georgia Department of Revenue to pay your tax delinquencies and continue to file all tax returns. If you are a business, all owners,
using a monthly payment plan. Your monthly payment amount and officers, partners, etc., must have filed all applicable Form GA-500
the length of time that you have to pay the liability is not based on Georgia Income Tax Returns.
your financial condition. Refer to page 4 of this application (Step 3: If our review indicates that you can pay the existing liability in full,
Figure your monthly payment amount) for further information. then we will require you to do so. If our review indicates that you
Please note that interest and penalty continue to accrue on the qualify for an installment payment plan, we will send you a letter of
installment payment plan liability and that the Department may still approval and the conditions of the installment payment plan.
issue and record a state tax execution, if neccessary. What payment method must I use?
Also, any refund due you in a future tax period may be applied You must make installment payments using the Automated Clearing
against the amount of your existing payment plan liability. If there House (ACH) debit program. This program allows you to have
remains a balance after the refund is applied, you are still required monthly payments automatically withdrawn from a checking or
to make regular monthly payments until the liability is paid in full. If savings account at a bank or other financial institution.
Form GA-9465 (Rev. 6/2009) Page 3
When is this form due?
There is no specific due date for this form. We recommend,
however, that you file this form as soon as you are aware that you
are unable to pay your tax liability due to a financial hardship. If you APPLING, ATKINSON, BACON,
have already received a proposed or official assessment from the BEN HILL, BERRIEN,
Department, you should return this form within 10 days of the BRANTLEY, CAMDEN,
assessment notice date. CHARLTON, CLINCH, COFFEE, Georgia Department of Revenue
COOK, ECHOLS, IRWIN, Douglas Regional Office
To what address do I mail this form? JEFF DAVIS, LANIER, 1214 N. Peterson Avenue
LOWNDES, MONTGOMERY, Douglas, GA 31533
• Income tax liability PIERCE, TELFAIR, TOOMBS,
TREUTLEN, WARE, WAYNE,
If your installment payment plan request involves an income tax WHEELER, WILCOX
liability, please return your completed form, along with any
attachments, using any of the following methods:
By mail: Georgia Department of Revenue
Installment Payment Unit
1800 Century Blvd., Suite 18225 Georgia Department of Revenue
Atlanta, Georgia 30345 DOUGLAS, PAULDING Lithia Springs Regional Office
351 Thornton Road, Suite 101
By Fax: (404) 417-4491
Lithia Springs, GA 30122-1596
By E-mail: firstname.lastname@example.org
• Sales and use tax liability
If your installment payment plan request involves a sales and use BALDWIN, BIBB, BLECKLEY,
tax liability, please return your completed form, along with any CRAWFORD, DODGE,
attachments, to the Georgia Department of Revenue at the address DOOLY, HANCOCK, Georgia Department of Revenue
below that applies to you. If you have a business in multiple HOUSTON, JASPER, Macon Regional Office
counties, choose a single mailing address. JOHNSON, JONES, LAMAR, 630 North Avenue, Suite B
Macon, GA 31211-1493
IF your business is in one of MONROE, PEACH, PULASKI,
the following counties. . . THEN use this address . . . PUTNAM, TWIGGS, UPSON,
BAKER, BROOKS, CALHOUN,
CLAY, COLQUIT, CRISP Georgia Department of Revenue
DECATUR, DOUGHERTY Albany Regional Office
EARLY, GRADY, LEE,
1105-D W. Broad Ave.
MILLER, MITCHELL, Georgia Department of Revenue
RANDOLPH, SEMINOLE, Albany, GA 31707 DEKALB, GWINNETT,
NEWTON, ROCKDALE North East Metro Office
SUMTER, TERRELL, 1800 Century Blvd, NE
THOMAS, TIFT, TURNER
Atlanta, GA 30345-3205
BANKS, BARROW, CLARKE,
DAWSON, ELBERT, FORSYTH,
FRANKLIN, GREENE, Georgia Department of Revenue BARTOW, CATOOSA,
HABERSHAM, HALL, HART, Athens Regional Office CHATTOOGA, CHEROKEE, Georgia Department of Revenue
JACKSON, LUMPKIN, DADE, FANNIN, FLOYD, Rome Regional Office
3700 Atlanta Hwy., Suite 268
MADISON, MORGAN, GILMER, GORDON, 1401 Dean Street, Suite E
Athens, GA 30606 HARALSON, MURRAY,
OCONEE, OGLETHORPE, Rome, GA 30161-6494
RABUN, STEPHENS, TOWNS, PICKENS, POLK, WALKER,
UNION, WALTON, WHITE WHITFIELD
BUTTS, CLAYTON, Georgia Department of Revenue
Atlanta Regional Office BRYAN, BULLOCH, CANDLER, Georgia Department of Revenue
FAYETTE, FULTON, Savannah Regional Office
HENRY, PIKE, SPALDING 4245 International Parkway CHATHAM, EFFINGHAM,
Hapeville, GA 30354 EVANS, GLYNN, LIBERTY, 6606 Abercorn Street, Suite 220
LONG, MCINTOSH, TATTNALL Savannah, GA 31405
BURKE, COLUMBIA, EMANUEL,
GLASCOCK, JEFFERSON, Georgia Department of Revenue
JENKINS, LINCOLN, MCDUFFIE, Augusta Regional Office
RICHMOND, SCREVEN, 130 Davis Road Where do I get help?
TALIAFERRO, WARREN, WILKES Martinez, GA 30907-2386 • Visit our web site at www.dor.ga.gov
• For sales and use tax, contact the revenue agent assigned to
CHATTAHOOCHEE, COWETA, Georgia Department of Revenue
HARRIS, HEARD, MARION, your account at the appropriate regional office. Phone numbers
Columbus Regional Office of all regional offices are located on the Department’s website.
QUITMAN, SCHLEY, STEWART, 1501 13th Street, Suite A
TALBOT, TAYLOR, TROUP, Columbus, GA 31901 • For income tax, contact the Installment Payment Plan Unit at
WEBSTER (404) 417-6486.
Form GA-9465 (Rev. 6/2009) Page 4
Specific Instructions Step 4: Provide your financial institution’s name and
account information and attach a voided check.
Which Parts must I complete?
Everyone must complete Steps 1, 3, 4, and 5. Complete Step 2 if Please complete all requested information about your financial
you are a business requesting an installment payment plan for a institution and account. Attach a blank check to your installment
sales and use tax liability only. payment request and mark “VOID” across the front. Do not use the
routing number indicated on your deposit slip. Return
To avoid processing delays:
• Complete all lines for each part that you are required to execute; The routing number can be found on the front of your check. (Note
and that the routing number is different on your checks and deposit
• Do not mail this form to the address on your tax return. Instead, slips; therefore, be sure to use the routing number on your check.)
mail it to the appropriate address provided under “To what address It is a nine-digit number; the first two digits of which must be 01
do I mail this form?” through 12 or 21 through 32. On the sample check on this page,
the routing number is 250250025. But if your check is payable
Step 1: Personal Information (include your spouse, if through a financial institution different from the one at which you
applicable) have your checking account, do not use the routing numbers on
Provide all requested information. If you are married, complete the that check. Instead, contact your financial insitution for the correct
lines regarding your spouse’s name, social security number, and routing numbers.
work phone number.
The account number can be up to 17 characters (both numbers and
Step 2: Identify your business and the person
letters). Include hyphens but omit spaces and special symbols. Enter
responsible for remitting payments (business only) the number from left to right and leave any unused boxes blank. On
Complete this section if you are a business requesting an the sample check on this page, the account number is 20202086. Do
installment payment plan. Be sure to provide all requested not include the check number.
information, including the name of the person who will be
responsible for remitting the installment plan payments. Please
include all relevant tax identification numbers.
Step 3:Figure your monthly payment amount
Line 3 Tell us whether or not you have filed all tax returns by
writing an “X” in the appropriate box provided. Note: If you have
not filed all tax returns, you must complete and attach those returns
to this form before we can consider your request.
Line 4 Choose the tax type covered by this agreement. Sales
and use tax and income tax cannot be covered by the same
payment plan form. If you want to enter into a payment plan for both
tax types, please use two separate forms.
Line 5 Identify all tax periods (i.e., month, quarter, or year) for
which the liability on Line 8 exists. For individual income tax Step 5: Signature authorization for taxpayer, authorized
liabilities, write the tax year covered by the return. If you need
officer, or partner
additional space, write the tax period beside the line provided or list
You (or in the case of a business, the person responsible for
the tax periods on a separate sheet of paper and attach it to this
remitting payments) must sign the statement. This signature
authorizes the Georgia Department of Revenue to use the
Line 6 Choose whether the payment plan will be for either information on this form to make monthly withdrawals from the
twelve months or longer. Note: If longer than twelve months, you account listed in Step 4. This authorization remains in force until the
must also provide either a completed Form CDLO-14C Statement Department receives written notification to the contrary from you.
of Financial Affairs for Businesses or Form CDLO-14B Statement of
Financial Affairs for Individuals. Both forms are available on the
Department’s website at www.dor.ga.gov.
Line 7 For income tax payment plans, all payments are auto-
matically debited on the tenth of each month. For sales and use tax
payment plans, please write the date or dates (1st to the 28th day)
of each month that you want to remit your payment.
Line 8 Enter the total amount of your unpaid liability.
Line 9 Enter the amount of your down payment. The down
payment must be equal or greater than 1/3 of your sales or use tax
liability. No down payment is required for an individual income tax
Line 10 Enter the amount of your requested monthly payment.
Please make the payment as large as possible to reduce
additional interest accural. Interest and penalty will continue
accrue monthly on the unpaid tax amount.