Clear form
                                                                     Utah State Tax Commission
                                                                              Business Tax                                                TC-804B
                                                                                                                                          Rev. 4/13
                                                            Payment Agreement Request

                                                                                               Get forms online - tax.utah.gov

DO NOT use this form if you are currently making payments on an existing payment agreement. Instead, call 801-297-7703 or 1-800-662-4335, ext. 7703
Business name                                                                                                     EIN or social security number (if sole proprietor)

Current address                                                                                                   Contact name

                                                                                                                  Daytime telephone number

                                                                                                                  Email address (required for pay plan reminders)

List all account numbers related to your business
Sales tax #: _________________________________________        Other tax types and #: _____________________________________
Withholding tax #: ___________________________________                                         #: _____________________________________

TIP: If you are submitting this form in response to a billing notice, do not complete lines 1 through 4.
Instead, attach the bottom section of the billing notice to this form and complete lines 5 through 7.

1. Enter the tax return form number for which you are making this request (example, “TC-20”)

2. Enter the tax year or period for which you are making this request
(example, “2011” or “Apr - Jun 2011 Qtr”)
3. Enter the total amount you owe as shown on your tax return                                                     $

4. Enter the amount of any payment you are making with your tax return or notice                                  $
Make your payment as large as possible to limit penalty and interest charges.

5. Enter the amount you can pay each month. Minimum payment requirements are:                                     $
     a. If the business is a sole proprietor or partnership, the payment should be large enough to
     pay off the tax due, penalty and interest within 24 months.
     b. If the business is a corporation, S-corporation, LLC or LLP and the tax amount due is:
     i. less than $5,000, your payment should be large enough to pay off the tax due, penalty
     and interest within 24 months (minimum payment $25).
     ii. equal to or greater than $5,000, three equal payments. If unable to pay in-full in
     90 days, contact the Tax Commission for further instructions.
Make your payment as large as possible to limit penalty and interest charges. Late filing, late payment
and extension penalties may apply. Interest will be assessed and continue to accrue until the amount
owed is paid in full. Penalty and interest information is available online at tax.utah.gov.

6. Enter the day of the month you want your payments to be due (example, “5th day” of
each month). Your payment must be received on or before the payment due date.
7. You must have filed tax returns for all prior filing periods before your pay plan will be approved.
If you have not, list the year(s) and tax types not filed and date you will be filing the returns.
Note: To enter into a pay plan you must file and pay future taxes on time and make your monthly pay plan payments to
the Tax Commission by the due date. If you do not meet these conditions, you default on your pay plan and are subject
to additional penalty, interest and fees. The Tax Commission may also record liens, garnish your wages and bank accounts,
take and sell your property, or refer your account to a collection agency.

I have read and understand the requirements of this request.
Authorized signature                                                                                                                      Date

If you need an accommodation under the Americans with Disabilities Act, contact the Tax Commission at 801-297-3811
or Telecommunications Device for the Deaf 801-297-2020. Please allow three days for a response.

Purpose of Form                                         Form Instructions
Use this form to request a monthly payment plan if      Enter the name, federal identification number (EIN)
you cannot pay the full amount you owe on your          of your business, contact name and telephone
business tax return (or on a billing notice we sent     number, and email for pay plan communication. If
you). Generally, you may have up to 3 months to         you are a sole proprietor with employees enter your
pay if the tax due is less than $5,000.                 EIN and social security number.

NOTE: A payment plan for individual income tax is       Line 4
requested on form TC-804.                               Enter any payment amount being paid with the
                                                        return or billing notice. Pay as much as possible to
Bankruptcy                                              lower the amount of penalty and interest you will be
If you are in bankruptcy do not use this form.          assessed.
Instead, call 801-297-6219 or if you are out of the
Salt Lake area 1-800-662-4335 extension 6219.           Line 5
                                                        Enter the amount you can pay monthly. Pay as
How Does the Agreement Process Work?                    much as possible each month to lower the amount
If your request is approved, we will send you an        of penalty and interest you will be assessed.
email. The email will confirm your monthly payment
amount and the number of required payments. It          Late filing, late payment and extension penalties
will also explain how to make your first payment.       may apply. Interest will be assessed and continue
You will have the following payment options:            to accrue until the amount owed is paid in full.
                                                        Penalty and interest information is available online
1. Pay by mail with check or money order.               at incometax.utah.gov.
2. Pay in person at one of our offices.
3. Pay by Internet at taxexpress.utah.gov.
                                                        Line 6
a. Electronic check (direct debit) from your            Enter the day of the month you want the payment
           checking or savings account.                 due. This is the day the payment must be received
b. Credit card (American Express, Discover              by the Tax Commission. Note: If you are mailing
           Card, MasterCard and Visa). You will be      your payment, allow 3 to 5 days for mail delivery.
           charged a fee each time you use this
           method of payment. The fee is based on       Line 7
           a percentage of the payment made.            You must have filed a return for all prior years or tax
                                                        periods. List the years for which you have not filed
By approving your request we agree to let you pay       a tax return. If you are unable to file a return due to
the tax you owe in monthly payments instead of          lost records you need to estimate your liability. Your
immediately paying the tax in full. In return you       payment agreement will not be approved until all
agree to make your monthly payments on time. You        returns have been filed. If you have questions
also agree to meet all of your future tax               contact us at 801-297-7703.
liabilities. This means that you must have enough
prepayments and proper securing of trust fund           Signatures
taxes so that your future tax liability is paid in full The business owner must sign the request.
when you file a timely return.
                                                        Submit to:
Any refund due you in a future year or tax period
will be applied against the amount you owe.                   Utah State Tax Commission
                                                              210 N 1950 W
Important Note: Failure to make your payments on              SLC, UT 84134-7000
time or failure to file and/or pay future returns when
                                                        or fax to: 801-297-6202
due, will break your payment agreement. If you
break the agreement we can take action to collect       Email Address Note: All communication on pay
the tax you owe in full and place liens on your real    plan is by email. Include your email address where
and tangible personal property. Business owners         indicated. The email address will be used to send
and officers of corporations, S-corporations and        you notice of approval and to remind you of your
limited liability companies may be assessed a           pay plan.
penalty equal to 100 percent of the tax due and
liens can be filed against real and personal
property.