Form TC-804 Fillable Individual Income Tax Payment Agreement Request
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

(Clear form) Clear form (text) (text) (text) (text) (text) (text) (text) (text) 1 Enter the income tax year for which you are making this request (example 2011 ) 2 Enter the total amount you owe as shown on your income tax return 210 N 1950 W 3 Enter the amount of any payment you are making with your tax return or notice 4 Enter the amount you can pay each month Your payment should be large enough to pay off 5 Enter the day of the month you want your payments to be due (example 5th day of each 6 You must have filed income tax returns for all prior years before your pay plan will be approved a percentage of the payment made against the amount you owe agree to make your monthly payments on time You also agree to meet all of your future tax amount and the number of required payments It amount of interest you will pay amount you owe as soon as you can to reduce the and tangible personal property Any future year refunds due you from the Internal assessed at incometax utah gov Bankruptcy break the agreement we can take action to collect By approving your request we agree to let you pay by the Tax Commission Note: If you are mailing cannot pay the full amount you owe now pay as Card MasterCard and Visa ) You will be charged a fee each time you use this checking or savings account contact us at 801 297 7703 Credit card (American Express Discover Daytime telephone number DO NOT use this form if you are currently making payments on an existing payment agreement Instead call 801 297 7703 or 1 800 662 4335 ext 7703 due This is the day the payment must be received due will break your payment agreement If you Electronic check (direct debit) from your Email address (required for pay plan reminders) Email Address Note: All communication on pay email The email will confirm your monthly payment Enter any payment amount being paid with the Enter the amount you can pay monthly Even if you Enter the day of the month you want the payment enter the names and social security numbers in the Evening telephone number Form Instructions Get forms online tax utah gov How Does the Agreement Process Work? I have read and understand the requirements of this request If a joint return spouse's full name (first middle last) If you are filing a request for a joint filed return the If you are in bankruptcy do not use this form If you are making this request for a joint filed return If you have not list the year(s) not filed and date you will be filing the returns If you need an accommodation under the Americans with Disabilities Act contact the Tax Commission at 801 297 3811 If your request is approved we will send you an immediately paying the tax in full In return you Important Note : Failure to make your payments on indicated The email address will be used to send Individual Income Tax individual income tax return (or on a billing notice Instead attach the bottom section of the billing notice to this form and complete lines 4 through 6 Instead call 801 297 6219 or if you are out of the is paid in full Penalty and interest information is available online at incometax utah gov Late filing late payment and extension penalties liabilities This means that you must have enough liability is paid in full when you file a timely return Line 3 Line 4 Line 5 Line 6 lower the amount of penalty and interest you will be Make your payment as large as possible to limit penalty and interest charges may apply Interest will be assessed and continue method of payment The fee is based on month) Your payment must be received on or before the payment due date months to pay However it is better to pay the much as possible each month to lower the amount NOTE: A payment plan for business taxes is Note: To enter into a pay plan you must file and pay future taxes on time and make your monthly pay plan payments to of penalty and interest you will be assessed or fax form to: 801 297 6202 or Telecommunications Device for the Deaf 801 297 2020 Please allow three days for a response Pay by Internet at taxexpress utah gov Pay by mail with check or money order Pay in person at one of our offices pay plan Payment Agreement Request payment agreement will not be approved until all penalties may apply Interest will be assessed and continue to accrue until the amount owed Penalty and interest information is available online plan is by email Include your email address where Purpose of Form records you need to estimate your liability Your requested on form TC 804B return If you are unable to file a return due to lost return or billing notice Pay as much as possible to returns have been filed If you have questions Rev 4/13 Revenue Service or the State will be applied Salt Lake area 1 800 662 4335 extension 6219 same order as they appear on your tax return your Signatures signatures of both taxpayers are required SLC UT 84134 7000 Spouse s signature (if joint return both must sign) Date Spouse's social security number Submit to: take and sell your property or refer your account to a collection agency TC 804 telephone numbers and email address the Tax Commission by the due date If you do not meet these conditions you default on your pay plan and are subject the tax due penalty and interest within 24 months Late filing late payment and extension the tax you owe in full and place liens on your real the tax you owe in monthly payments instead of the years for which you have not filed an income tax time or failure to file and/or pay future returns when TIP: If you are submitting this form in response to a billing notice do not complete lines 1 through 3 to accrue until the amount owed is paid in full to additional penalty interest and fees The Tax Commission may also record liens garnish your wages and bank accounts Use this form to request a monthly payment plan if Utah State Tax Commission Utah State Tax Commission we sent you) Generally you may have up to 24 will also explain how to make your first payment withholding or prepayments so that your future tax you cannot pay the full amount you owe on your You must have filed a return for all prior years List you notice of approval and to remind you of your You will have the following payment options: Your current address Your employer(s) name address and telephone number Spouse s employer(s) name address and telephone number Your full name (first middle last) your payment allow 3 to 5 days for mail delivery Your signature Date Your social security number