Installment Agreement Request
DE 927B Rev. 1 (4-12) (INTERNET) P.O. BOX 989150, MIC 92F • WEST SACRAMENTO, CA 95798-9150 CU
Installment Agreement Request
On behalf of the business identified below, as an individual owner, partner or representative of the corporation, I request that
the Employment Development Department (EDD) accept an installment agreement in order to liquidate debts due. The
following is submitted, along with a Good Faith payment, in consideration of this request:
Employer Account Number
Owner Name Social Security No. or Corporate ID No.
Business Name
Address (number and street)
City, State, and ZIP Code
Mailing Address (if different from above)
City, State, and ZIP Code
If you are an individual owner, partner, or a person assessed under
Section 1735 of the CUIC and no longer in business, complete the following:
Name of Bank or Other Financial Institution
Current Employer’s Name
Address Address
City, State, and ZIP Code
City, State, and ZIP Code
Proposed payment amount:
Frequency (check one): Monthly Bi-weekly Weekly
$
Good Faith payment enclosed:
$
I understand:
The EDD has the right to refuse this installment agreement request.
Installment agreements exceeding one year in length require full financial disclosure and documentation.
Additional interest accrues daily on the unpaid balance at the rate prescribed by law.
All missing and delinquent reports must be filed in order to request a payment arrangement.
The EDD will file a Notice of State Tax Lien for outstanding liabilities.
I will be subject to an offset of any state refund due to me, including State Income Tax refunds and Lottery winnings,
as well as any Federal Income Tax refund due to me by the U.S. Department of the Treasury, as prescribed by law.
The EDD may assess responsible individuals for any unpaid corporate, limited liability company, or limited liability
partnership liability.
Failure to adhere to the installment agreement and/or incurring any additional liability may be considered a default,
and involuntary collection action may be taken without further notice to me or to the organization listed above.
Signature (Owner/Responsible Party) Title Date
( ) - ( ) -
Print Name Phone Number Alternate Phone Number
( ) - ( ) -
Contact Person (please print) Phone Number Alternate Phone Number
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