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