Sample Form for Installment Agreement
Income Tax Bureau
Post Office Box 22805
Jackson, MS 39225-2805
If this address is new since you filed your last tax return, check here:
Spouse social security number
Your social security number
If joint return, spouse's first name and initial
City, Town, or Post Office, State, and ZIP Code.
Your current address (number and street). If you have a P.O. box and no home delivery, enter your box number.
Form 71-661-10-8-1-000 (Rev. 05/10)
Your employer's name:
City, State, Zip Code
Your first name and initial
Name of your bank or other financial institution:
City, State, Zip Code
Caution: Do not file this form if you are currently making payments on an installment agreement. If you are in
bankruptcy, see instructions.
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9.Enter the amount due each month. Interest will continue until you pay in full.
Enter the total amount you owe (as shown on your return).
Enter the amount of any payment you are making with your tax return (See instructions).
Round to whole dollars.
Must Be Attached To Front Of Return
Duplex and Photocopies NOT Acceptable
Enter the tax year for which you are making this request.
An installment agreement is available to taxpayers that have a tax liability of at least $75. In order to qualify for the
installment agreement, the return must be filed on or before the due date, or any extensions allowed, and this
request form must be submitted with the return. You (and your spouse if a joint return) must have filed all required
income tax returns and paid all taxes due for the past five years. You also can not have previously entered into an
installment agreement during the past five years.
There are two (2) types of installment agreements for taxpayers that have a tax liability:
(1) Tax liability of $75 but no more than $3,000 - The installment agreement allows you to pay the amount
(2) Tax liability exceeding $3,000 and an installment agreement with the Internal Revenue Service (IRS)
for the same tax year - The installment agreement allows you to pay the amount due within up to sixty
up to sixty months. Must attach a copy of the approved installment agreement notification from the IRS.
The agreement may be terminated if any installment payment is not made timely. It may also be terminated if you
do not pay any other tax liability when the liability is due.
Interest of one percent (1%) per month continues to accrue during the installment agreement period. You will need
to contact our office for the remaining balance on the account prior to the last payment to ensure the interest is paid
If you have a pending bankruptcy case, you may be barred by federal law from participation in an installment
agreement; please contact our office for more details. Additionally, if you file bankruptcy during the installment
period, you must notify our Bankruptcy Section immediately at 601-923-7393; due to the automatic stay provisions
of the U.S. Bankruptcy Code the installment agreement may be void at the time you file your bankruptcy case.
Sample Form for Installment Agreement PDF
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