Form 433 D (Rev. 1 2017) 4033D F433d

Catalog Number 16644M www.irs.gov Form 433-D (Rev. 1-2017)

Part 1 — IRS Copy

Form 433-D

(January 2017)

Department of the Treasury - Internal Revenue Service

Installment Agreement

(See Instructions on the back of this page)

Name and address of taxpayer(s)

Submit a new Form W-4 to your employer to increase your

Social Security or Employer Identification Number (SSN/EIN)

1-800-829-0922 (Individuals – Wage Earners)

Or write

Kinds of taxes (form numbers) Tax periods Amount owed as of

I / We agree to pay the federal taxes shown above, PLUS PENALTIES AND INTEREST PROVIDED BY LAW, as follows

$ on and $ on the of each month thereafter

I / We also agree to increase or decrease the above installment payments as follows:

DIRECT DEBIT — Attach a voided check or complete this part only if you choose to make payments by direct debit. Read the instructions on the

back of this page.

a. Routing number

b. Account number

I authorize the U.S. Treasury and its designated Financial Agent to initiate a monthly ACH debit (electronic withdrawal) entry to the financial

institution account indicated for payments of my federal 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 Internal Revenue Service to terminate the authorization. To revoke payment, I

must contact the Internal Revenue Service at the applicable toll free number listed above no later than 14 business days prior to the payment

(settlement) date. I also authorize the financial institutions involved in the processing of the electronic payments of taxes to receive confidential

information necessary to answer inquiries and resolve issues related to the payments.

RSI “5” PPIA IMF 2 year review AI “1” Field Asset PPIA

RSI “6” PPIA BMF 2 year review AI “2” All other PPIAs

Check box if pre-assessed modules included

Originator’s ID number Originator Code

Name Title

Catalog Number 16644M www.irs.gov Form 433-D (Rev. 1-2017)

Part 2 — Taxpayer’s Copy

Form 433-D

(January 2017)

Department of the Treasury - Internal Revenue Service

Installment Agreement

(See Instructions on the back of this page)

Name and address of taxpayer(s)

Submit a new Form W-4 to your employer to increase your

Social Security or Employer Identification Number (SSN/EIN)

1-800-829-0922 (Individuals – Wage Earners)

Or write

Kinds of taxes (form numbers) Tax periods Amount owed as of

I / We agree to pay the federal taxes shown above, PLUS PENALTIES AND INTEREST PROVIDED BY LAW, as follows

$ on and $ on the of each month thereafter

I / We also agree to increase or decrease the above installment payments as follows:

DIRECT DEBIT — Attach a voided check or complete this part only if you choose to make payments by direct debit. Read the instructions on the

back of this page.

a. Routing number

b. Account number

I authorize the U.S. Treasury and its designated Financial Agent to initiate a monthly ACH debit (electronic withdrawal) entry to the financial

institution account indicated for payments of my federal 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 Internal Revenue Service to terminate the authorization. To revoke payment, I

must contact the Internal Revenue Service at the applicable toll free number listed above no later than 14 business days prior to the payment

(settlement) date. I also authorize the financial institutions involved in the processing of the electronic payments of taxes to receive confidential

information necessary to answer inquiries and resolve issues related to the payments.

RSI “5” PPIA IMF 2 year review AI “1” Field Asset PPIA

RSI “6” PPIA BMF 2 year review AI “2” All other PPIAs

Check box if pre-assessed modules included

Originator’s ID number Originator Code

Name Title

Catalog Number 16644M www.irs.gov Form 433-D (Rev. 1-2017)

Part 2 — Taxpayer’s Copy

• Your home and work, cell or business telephone numbers;

• The complete name, address and phone number of your employer and your financial institution;

• The amount you can pay now as a partial payment;

• The amount you can pay each month (or the amount determined by IRS personnel); and

• The date you prefer to make this payment (This must be the same day for each month, from the 1st to the 28th). We must receive your payment by this date.

If you elect the direct debit option, this is the day you want your payment electronically withdrawn from your financial institution account.

Review the terms of this agreement.

When you’ve completed this agreement form, please sign and date it. Then, return Part 1 to IRS at the address on the letter

that came with it or the address shown in the “For assistance” box on the front of the form.

significantly changed. You must provide updated financial information when requested.

• While this agreement is in effect, you must file all federal tax returns and pay any (federal) taxes you owe on time.

• We will apply your federal tax refunds or overpayments (if any) to the entire amount you owe, including the shared responsibility payment under the

Affordable Care Act, until it is fully paid or the statutory period for collection has expired.

• You must pay a $225 user fee, which we have authority to deduct from your first payment(s) ($107 for Direct Debit).

• In lieu of the above user fees, you may be eligible for a reduced user fee of $43. See Form 13844 for qualifications and instructions.

• If you default on your installment agreement, you must pay a $89 reinstatement fee if we reinstate the agreement. We have the authority to deduct this fee

from your first payment(s) after the agreement is reinstated.

• We will apply all payments on this agreement in the best interests of the United States. Generally we will apply the payment to the oldest collection statute,

which is normally the oldest tax year or period.

• This agreement may require managerial approval. We’ll notify you when we approve or don’t approve the agreement.

• We may file a Notice of Federal Tax Lien if one has not been filed previously which, may negatively impact your credit rating, but we will not file a Notice of

Federal Tax Lien with respect to the individual shared responsibility payment under the Affordable Care Act.

Instead of sending us a check, you can pay by direct debit (electronic withdrawal) from your checking account at a financial institution (such as a bank, mutual

fund, brokerage firm, or credit union). To do so, fill in Lines a and b. Contact your financial institution to make sure that a direct debit is allowed and to get the

correct routing and account numbers.

Line a. The first two digits of the routing number must be 01 through 12 or 21 through 32. Don’t use a deposit slip to verify the number because it may contain

internal routing numbers that are not part of the actual routing number.

Line b. The account number can be up to 17 characters. Include hyphens but omit spaces and special symbols. Enter the number from left to right and leave any

5. Enclose a copy of the reminder notice, if you received one, with each payment using the envelope provided. Make a payment even if you do not receive a

reminder notice, write the type of tax, the tax period and "Installment Agreement" on your payment. For example, "1040, 12/31/2014, Installment Agreement”.

You should choose the oldest unpaid tax period on your agreement. Mail the payment to the IRS address indicated on the front of this form.

6. If you didn’t receive an envelope, call the number below.

This agreement will not affect your liability (if any) for backup withholding under Public Law 98-67, the Interest and Dividend Compliance Act of 1983

QUESTIONS? — If you have any questions, about the direct debit process or completing this form, please call the applicable telephone number below for

1-800-829-0115 (Business)

1-800-829-8374 (Individuals – Self-Employed / Business Owners)

1-800-829-0922 (Individuals – Wage Earners)