RO1033 2007 WebFill 000
RO-1033
Installment Agreement Request
Web-Fill
3-07
North Carolina Department of Revenue
4
✖
PRINT
CLEAR
Please print legibly using all capital letters in blue or black ink.
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 Corporation)
Federal Employer ID Number
Home Telephone Number (Include area code.)
Daytime Telephone Number (Include area code.)
If Joint, Spouse’s Daytime Telephone Number
Address
County (Enter first five letters)
City
State
Zip Code
Country (If not U.S.)
Part 1. Installment Request
1. Enter total account balance for all periods (F-502 Agreement Amount)
1.
2. Enter installment amount
2.
3. Enter first installment date
3.
Must be between the 1st and 28th of each month.
(MM-DD-YYYY)
4. Payment Frequency
If date falls on a weekend or holiday, the transfer will occur on the next business day.
Fill in applicable circle:
Monthly
2 x Month (1st and 15th ONLY)
Weekly
(Please fill in corresponding day, i.e. MO, TU, WE, TH, FR.
Day must correspond with the first insallment date.)
Part 2. Bank Account Information
(Approved agreements must be paid in monthly or semimonthly installments by direct transfer from your bank account.)
4. Financial Institution Name
5. Account Type
6. Transit or Routing Number
7. Bank Account Number
Fill in applicable circle:
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
Installment Agreement Request
Web-Fill
3-07
North Carolina Department of Revenue
4
✖
CLEAR
Please print legibly using all capital letters in blue or black ink.
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 Corporation)
Federal Employer ID Number
Home Telephone Number (Include area code.)
Daytime Telephone Number (Include area code.)
If Joint, Spouse’s Daytime Telephone Number
Address
County (Enter first five letters)
City
State
Zip Code
Country (If not U.S.)
Part 1. Installment Request
1. Enter total account balance for all periods (F-502 Agreement Amount)
1.
2. Enter installment amount
2.
3. Enter first installment date
3.
Must be between the 1st and 28th of each month.
(MM-DD-YYYY)
4. Payment Frequency
If date falls on a weekend or holiday, the transfer will occur on the next business day.
Fill in applicable circle:
Monthly
2 x Month (1st and 15th ONLY)
Weekly
(Please fill in corresponding day, i.e. MO, TU, WE, TH, FR.
Day must correspond with the first insallment date.)
Part 2. Bank Account Information
(Approved agreements must be paid in monthly or semimonthly installments by direct transfer from your bank account.)
4. Financial Institution Name
5. Account Type
6. Transit or Routing Number
7. Bank Account Number
Fill in applicable circle:
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