IRS 433-D Installment Agreement Form

In the case of wanting to reach an installment agreement with the IRS, the following form has to be completed and submitted.

Extracted Text for Proper Search

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 
withholding. 	
Social security or employer identification number (Taxpayer)  (Spouse) 
(Home)  (Work, cell or business)
Your telephone numbers	 (including area code) 	
For assistance, call:  	1-800-829-0115 	(Business), 	 or 
1-800-829-8374 	(Individual – Self-Employed/Business Owners)	,   or 
1-800-829-0922 	(Individuals – Wage Earners) 	
(City, State, and ZIP Code) 	Or write: 
Employer	
 (Name, address, and telephone number) 	
Financial Institution 	(Name and address) 	
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 payment as follows: 
Date of increase 	(or decrease) 	Amount of increase 	(or decrease) 	New installment payment amount 	
The terms of this agreement are provided on the back of this page. Pleas\
e review them thoroughly.
 Please initial this box after you’ve reviewed all terms and any additional conditions. 
Additional Conditions / Terms   	(To be completed by IRS) 	Note: Internal Revenue Service employees 
may contact third parties in order to process 
and maintain this agreement. 	
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 U.S. Treasury Financial Agent to terminate the authorization. To revoke 
payment, I must contact the U.S. Treasury Financial Agent 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. 	
Your signature  Title	 (if Corporate Officer or Partner) 	Date 
Spouse’s signature	
 (if a joint liability) 	Date 
Agreement examined or approved by 	
(Signature, title, function) 	Date 	
FOR IRS USE ONLY  AGREEMENT LOCATOR NUMBER: Check the appropriate boxes: A NOTICE OF FEDERAL TAX LIEN 	
(Check one box below.) 	
RSI “1” no further review
 AI “0” Not a PPIA
HAS ALREADY BEEN FILED 
RSI “5” PPIA IMF 2 year review  AI “1” Field Asset PPIA
WILL BE FILED IMMEDIATELY 
RSI “6” PPIA BMF 2 year review  AI “2” All other PPIAs 
WILL BE FILED WHEN TAX IS ASSESSED 
Agreement Review Cycle:  Earliest CSED:
MAY BE FILED IF THIS AGREEMENT DEFAULTS 
Check box if pre-assessed modules included 
Originator’s ID #:  Originator Code: 
Name:  Title:	
Part 1— IRS Copy 	Catalog No. 16644M www.irs.gov 	
Form 	433-D 	
(Rev. January 2012) 
Form 	
433-D	 (Rev. 1-2012)

AGREEMENT LOCATOR NUMBER DESIGNATIONS
 	
XX Position 	(the first two numbers) 	denotes either the Initiator or Type of Agreement. The XX values are: 
00  Form 433-D initiated by AO on an ACS case
01  Customer Service Toll-free initiated agreements
02  AO Field Territory 	
(revenue officer)	 initiated agreements
03  Direct Debit agreements initiated by any function
06  Exam initiated agreements
07  Submission Processing initiated agreements
08  Agreements initiated by other functions
11  Form 2159 agreement initiated by AO, ACS or Customer Service
12  AO or ACS agreement with multiple conditions
20  Status 22/24 accounts – Call Site/CSCO
90  CSCO initiated agreements – other than status 22 or 26
91  Form 2159 agreement initiated by CSCO
92  CSCO agreement with multiple conditions
99  Up to 120 days extensions 	
(NOT FOR FIELD) 	
YY Position 	(the second two numbers)	 denotes Conditions Affecting the Agreement. The YY values are: 
08  Continuous Wage Levy 	
(from ACS and RO) 	09 	All other conditions 	12 	Partial Pay Installment Agreement (PPIA) 	all functions 
15  In Business Trust Fund 	(IBTF)	 monitoring required for all functions
27  Restricted Interest/Penalty condition present
32  Unassessed modules to be included in agreement
36  Streamlined agreements, less than 60 months, up to $25,000
41  BMF in Business Deferral Level 	
(CSCO USE ONLY) 	53 	Report Currently Not Collectible (CNC)	 if agreement defaults
63  Cross-reference TIN 	(Status 63) 	66 	File lien in event of default 	70 	Secondary TP responsible for Joint Liability 	80 	Review and revise payment amount 	99 	Up to 120 days extensions (NOT FOR FIELD) 	
When an agreement has more than one condition, use either 12 or 92 in the “XX” position and assign the primary condition (YY)	 based on the following priorities: 
#1-63, #2-12, #3-53, or #4-32 
The remaining multiple conditions will be input as a history item on IDRS. 	
INSTALLMENT AGREEMENT ORIGINATOR CODES 
20  Collection field function regular agreement
21  Collection field function streamlined agreement
30  Reserved 
31  Reserved 
50  Field assistance counter – regular agreement
51  Field assistance counter – streamlined agreement
60  Examination regular agreement
61  Examination streamlined agreement
70  Toll-free regular agreement
71  Toll-free streamlined agreement
72  Paper regular agreement CSCO
73  Paper streamlined agreement CSCO
74  Voice Response Unit 	
(system generated)	75 Automated Collection Branch regular
76  Automated Collection Branch streamlined 
77  Automated Collection Branch Voice Response Unit regular	
 (system generated)	78 Automated Collection Branch Voice Response Unit streamlined 	(system generated)	80 Other function regular agreement
81  Other function-streamlined agreement
82  Electronic Installment Agreement 	
(e-IA)	 - AM 
83  Electronic Installment Agreement 	(e-IA)	 - ACS 
90-91  Reserved for vendors – all streamlined agreements 	
IRS Copy 	Catalog No. 16644M  www.irs.gov 	Form 	433-D	 (Rev. 1-2012)

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 
withholding. 	
Social security or employer identification number (Taxpayer)  (Spouse) 
(Home)  (Work, cell or business)
Your telephone numbers	 (including area code) 	
For assistance, call:  	1-800-829-0115 	(Business), 	 or 
1-800-829-8374 	(Individual – Self-Employed/Business Owners)	,   or 
1-800-829-0922 	(Individuals – Wage Earners) 	
(City, State, and ZIP Code) 	Or write: 
Employer	
 (Name, address, and telephone number) 	
Financial Institution 	(Name and address) 	
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 payment as follows: 
Date of increase 	(or decrease) 	Amount of increase 	(or decrease) 	New installment payment amount 	
The terms of this agreement are provided on the back of this page. Pleas\
e review them thoroughly.
 Please initial this box after you’ve reviewed all terms and any additional conditions. 
Additional Conditions / Terms   	(To be completed by IRS) 	Note: Internal Revenue Service employees 
may contact third parties in order to process 
and maintain this agreement. 	
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 U.S. Treasury Financial Agent to terminate the authorization. To revoke 
payment, I must contact the U.S. Treasury Financial Agent 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. 	
Your signature  Title	 (if Corporate Officer or Partner) 	Date 
Spouse’s signature	
 (if a joint liability) 	Date 
Agreement examined or approved by 	
(Signature, title, function) 	Date 	
FOR IRS USE ONLY  AGREEMENT LOCATOR NUMBER: Check the appropriate boxes: A NOTICE OF FEDERAL TAX LIEN 	
(Check one box below.) 	
RSI “1” no further review
 AI “0” Not a PPIA
HAS ALREADY BEEN FILED 
RSI “5” PPIA IMF 2 year review  AI “1” Field Asset PPIA
WILL BE FILED IMMEDIATELY 
RSI “6” PPIA BMF 2 year review  AI “2” All other PPIAs 
WILL BE FILED WHEN TAX IS ASSESSED 
Agreement Review Cycle:  Earliest CSED:
MAY BE FILED IF THIS AGREEMENT DEFAULTS 
Check box if pre-assessed modules included 
Originator’s ID #:  Originator Code: 
Name:  Title:	
Catalog No. 16644M www.irs.gov 	Form 	433-D	 (Rev. 1-2012) 
Part 2 — Financial Institution Copy 	(Direct Debit only) 	
Form 	433-D 	
(Rev. January 2012)

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 
withholding. 	
Social security or employer identification number (Taxpayer)  (Spouse) 
(Home)  (Work, cell or business)
Your telephone numbers	 (including area code) 	
For assistance, call:  	1-800-829-0115 	(Business), 	 or 
1-800-829-8374 	(Individual – Self-Employed/Business Owners)	,   or 
1-800-829-0922 	(Individuals – Wage Earners) 	
(City, State, and ZIP Code) 	Or write: 
Employer	
 (Name, address, and telephone number) 	
Financial Institution 	(Name and address) 	
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 payment as follows: 
Date of increase 	(or decrease) 	Amount of increase 	(or decrease) 	New installment payment amount 	
The terms of this agreement are provided on the back of this page. Pleas\
e review them thoroughly.
 Please initial this box after you’ve reviewed all terms and any additional conditions. 
Additional Conditions / Terms   	(To be completed by IRS) 	Note: Internal Revenue Service employees 
may contact third parties in order to process 
and maintain this agreement. 	
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 U.S. Treasury Financial Agent to terminate the authorization. To revoke 
payment, I must contact the U.S. Treasury Financial Agent 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. 	
Your signature  Title	 (if Corporate Officer or Partner) 	Date 
Spouse’s signature	
 (if a joint liability) 	Date 
Agreement examined or approved by 	
(Signature, title, function) 	Date 	
FOR IRS USE ONLY  AGREEMENT LOCATOR NUMBER: Check the appropriate boxes: A NOTICE OF FEDERAL TAX LIEN 	
(Check one box below.) 	
RSI “1” no further review
 AI “0” Not a PPIA
HAS ALREADY BEEN FILED 
RSI “5” PPIA IMF 2 year review  AI “1” Field Asset PPIA
WILL BE FILED IMMEDIATELY 
RSI “6” PPIA BMF 2 year review  AI “2” All other PPIAs 
WILL BE FILED WHEN TAX IS ASSESSED 
Agreement Review Cycle:  Earliest CSED:
MAY BE FILED IF THIS AGREEMENT DEFAULTS 
Check box if pre-assessed modules included 
Originator’s ID #:  Originator Code: 
Name:  Title:	
Catalog No. 16644M www.irs.gov 	Form 	433-D	 (Rev. 1-2012) 
Part 3 — Taxpayer’s Copy  Form 	
433-D 	
(Rev. January 2012)

INSTRUCTIONS TO TAXPAYER
 	
If not already completed by an IRS employee, please fill in the information in the spaces provided on the front of this form for: 
CHECKLIST FOR MAKING INSTALLMENT PAYMENTS: 	
Form 	433-D	 (Rev. 1-2012)