North Carolina Department of Revenue
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2017 Tax Year: You should complete this form after you have received a bill or notice from the Department




Installment Agreement Request

North Carolina Department of Revenue
Individual's First Name M.I. Individual's Last Name Individual's Social Security Number
Spouse's First Name  (if joint liability) M.I. Spouse's Last Name  (if joint liability) Spouse's Social Security Number  (if joint liability)
Entity's Legal Name  (if Corporate) Federal Employer ID Number
Daytime Telephone Number  (Include area code) Home Telephone Number  (Include area code) If Joint Spouse's Telephone Number
Address County  (Enter the first five letters)
City State Zip Code Country  (If not U.S.)
Part 1. Installment Request
1. Enter total account balance for all periods 1.
2. Enter installment amount 2.
3. Enter first installment date 3.
(MM-DD-YYYY)(date should be between 1 and 28 of the month)
4. Payment Frequency
If date falls on weekend or holiday, the transfer will occur on the next business day.
Monthly Weekly (Please select corresponding day.
2 x Month (1st and 15th ONLY) Day must correspond with the first installment date.)
Part 2. Bank Account Information (Approved agreements must be paid in monthly or semimonthly installments by direct transfer from your bank account.)
5. Financial Institution Name
6. Account Type 7. Transit or Routing Number 8. Bank Account Number
Personal Checking Personal Savings
Business Checking Business Savings
Part 3. Authorized Signature (The Installment Agreement must be signed by the taxpayer or an individual authorized to act on behalf of the taxpayer. Generally this is the person with the authority to sign a tax return. )

I certify that I have the authority to request an electronic debit from the account named above, and I authorize the N.C. Department of Revenue to present debit entries for the bank account and the financial institution named above. This authorization will remain in effect until the balance due has been paid, the N.C. Department of Revenue cancels the installment agreement, or a written notification from the taxpayer to stop the debit transactions has been received and processed. The N.C. Department of Revenue may cancel the installment agreement and charge the taxpayer a dishonored payment penalty and a collection fee if the monthly payment cannot be deducted due to insufficient funds or because the account is closed. The taxpayer will be responsible for any overdraft fees charged by the bank.

If this request is accepted by the N.C. Department of Revenue and an installment agreement is established, the following conditions apply: The agreement is based on the taxpayer's current financial circumstances and is subject to revision or termination if subsequent financial information required by the N.C. Department of Revenue reflects a change in the taxpayer's ability to pay. Failure to provide updated financial information when requested by the N.C. Department of Revenue will be reason for termination of the agreement. All State taxes and all State returns that become due during the term of the agreement must be filed on time. Any State and Federal refunds that might otherwise be due may be applied to this liability until it is satisfied. If the conditions of the installment agreement are not met, it will be terminated, and the entire tax liability will be due. The agreement may be terminated if collection of the tax liability is in jeopardy. This request may require managerial approval: you will be notified if it is not approved. If you are granted an installment agreement and subsequently default on that agreement, you will NOT be eligible for another installment agreement with the N.C. Department of Revenue.

By submitting this form, I hereby certify that, to the best of my knowledge, this form is accurate and complete.

Print Name Title (if business) Date (MM-DD-YYYY)

If you have any questions about your installment agreement request, call toll free 1 (877) 252-3052. An interactive Voice Response System is available at all times. Our representatives are available weekdays from 8:00 a.m. to 5:00 p.m.

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