INSTALLMENT PLAN AGREEMENT
Log No. _________________
Name ____________________________________ Account Balance __________
DBA _____________________________________ Amount of Offer __________
Account No. _______________________________ Date ___________________
I promise to satisfy the amount offered, by paying the sum of $ __________________ .
I understand that the initial payment of $ ____________ is due on ______________ .
Subsequent installments in the amount of $ _____________ will be paid on the same
day of each succeeding ____________________________ until the entire amount
has been paid in full.
I further understand that failure to pay as promised will result in termination of the Offer
in Compromise, and monies paid to the Department will be applied against the total
I certify that I have read and fully understand the conditions and terms of this
agreement as stated on the Installment Plan Information Sheet.
By____________________ Title _________________ Date _________________
DE 999D (7-03) (INTERNET)
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INSTALLMENT PLAN INFORMATION SHEET
The offers in compromise program allows for installment payments under an
agreement not to exceed five years.
ABILITY TO PAY
An installment plan will be considered ONLY if you demonstrate the inability to
pay the compromised amount in full.
REQUIREMENT OF PARTIAL PAYMENT
Your offer must not exceed a five year period. Payment must be submitted in
the form of cash (Do not send cash through the mail), cashiers check or money
All payments made with this offer are submitted voluntarily. In the event an offer
is not accepted, the amount will either be applied to the liability or refunded at
the discretion of the employer or individual submitting the offer.
When entering into a partial payment agreement to satisfy amount offered and
the applicant defaults, the agreement will be rescinded. All compromised
liabilities and liens will be reestablished without regard to statute of limitations.
All monies paid on compromised amount