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State of Rhode Island and Providence Plantations
Form RI-9465
Installment Agreement Request
Your name Social security/federal identification number
Address For the tax year
Address 2
City, town or post office State ZIP code
GENERAL INFORMATION
The Rhode Island Division of Taxation may afford you the opportunity to enter into an installment agreement
should you be able to present facts that you are unable to pay the balance in full at this time. Down payment of half
of the balance owed will be required.
Approval for such an agreement will be based upon the information that is outlined below and must shall be
submitted to this office. All requests for an agreement along with any payments shall be forwarded to:
RHODE ISLAND DIVISION OF TAXATION, COLLECTIONS SECTION
ONE CAPITOL HILL, STE 10, PROVIDENCE, RI 02908-5812
The information will be reviewed by the Compliance and Collections Section for final approval. Within thirty days
of receipt of your proposed agreement, including all required information, you will be notified in writing of the approval
or denial.
The agreement will be revoked for failure to meet the agreed upon monthly payment and/or failure to file and pay
all future tax returns on a timely basis.
In the absence of an approved agreement or default of such agreement, collection procedures will resume which
may result in levy of assets and wages or other appropriate legal action.
Balance owed as of today. (Interest
and penalties will continue to accrue Proposed Monthly Payment
until balance is paid in full.)
NOTE: DOWN PAYMENT MUST ACCOMPANY THIS FORM
Please circle the date you choose to make your payment each month: 15th Day 30th Day
Name and address of employer(s):
Bank Name: ________________________________________________________________________________
Checking - Account number: _________________________________________________
Savings - Account number: ___________________________________________________
Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and
belief, it is true, accurate and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Signature of taxpayer Print name Date Telephone number
Signature of spouse (if applicable) Print name Date Telephone number
The law authorizes the filing of State Tax Liens.
Failure to pay the total liability in full will result in the filing of a Tax Lien.
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