PDF document

- 1 -

                                                                     Click on (i) for instructions  Reset Form                                Print
      
    Michigan Department of Treasury 
    990 (Rev. 04-18) 
    Installment Agreement 
      Issued under the authority of P.A. 122 of 1941, as amended.                                     Treasury Account Number 
      You must file this form if you wish to establish an installment agreement.                    (i)           
(i)   Name and Address                                                                             (i)Type of Entity 
                                                                                                                                 Individual              Sole Proprietor 
                 
                                                                                                                                 Corporation             Partnership 
                                                                                                             Other, specify: ___________________________________ 
                                                                                                      Home Telephone Number                   Business Telephone Number 
                                                                                                       
    I (We) request an installment agreement to liquidate my (our) debt to the Michigan Department of Treasury and agree to pay the assessment(s) listed 
    below in the following manner (attach additional sheets if necessary): 
      (i) Assessment Number              Assessment Number                       Assessment Number     Assessment Number                           Assessment Number 
                                                                                                                                                         
                                                                                                                    TOTAL AMOUNT               
                                                                                                                    OUTSTANDING 

    If a business, enter information about all owners, partners, officers, major shareholders, etc. 
                                                     Effective                                                                                Social Security  % of 
                 Name and Title                      Date                        Home Address          Phone Number                           Number          Ownership 
                                                                                                                                                               
(i) Proposed monthly payments $ ______          ____________ due on or before the ___          _________  due date 
    Proposed Bi-Weekly payments $ ____          ____________ due on or before the ___          _________  due date  
     
      Signature Required (and Title if Corporate Officer or Partner)                                  Social Security Number                       Date 
      (i) 
      Spouse Signature (and Title if Corporate Officer or Partner)                                    Social Security Number                       Date 
       
      (i)
    Your request for an installment agreement to liquidate your debt to the Michigan Department of Treasury will be reviewed. If it is not approved, you will be 
    notified. Make checks and money orders payable to “State of Michigan – OC”, and include your account number (Social Security number, FEIN, or Michigan 
    Department of Treasury Account number) to ensure proper handling. 
      Bank Name and Address (required)                                                      Employer Name and Address (required) 
                                                                                             
    Read carefully. You should understand that this installment agreement is granted under the following conditions. 
(i)       If a tax debt: 
    •     Liens will be filed against your real and personal property to protect the interest of the State (this is a public record). 
    •     Penalty will be charged as provided by statute. 
    •     Interest will be charged each month on the unpaid balance as provided by statute. 
          All other debts: 
    •     All delinquent tax returns must be filed. 
    •     All tax returns and estimated payments that become due during the term of this agreement must be filed and paid on time. 
    •     Permission to make installment payments may be withdrawn and the entire tax liability may be collected by levy on income or by seizure of property without further notice 
          if the conditions of this agreement are not met, or if it is determined that collection of these taxes is endangered.  
    •     Application of payments under this agreement is at the discretion of the Michigan Department of Treasury. 
    •     If debt is a student loan, interest at the rate specified in the agreement will continue to accrue. Payment of the principal does not clear your liability until the related interest 
          is computed and paid. 
    •     Any refund, vendor payment, or other credit due to you from the State of Michigan may be applied as an additional payment on this debt. When applicable, your federal 
          income tax refund may be applied. 
    •     This agreement is based on your current financial circumstances and is subject to periodic reviews, revision, and cancellation if subsequent financial statements required 
          by the Michigan Department of Treasury reflect a change in your ability to pay. 
    •     If receiving vendor income you MUST also complete Collection Information Statement Form 3189 for Individuals or Form 856 for Businesses.

- 2 -

    Michigan Department of Treasury
    990 (Rev. 02-14)                                                                               PLEASE State of Michigan - OC
                                                                                                    REMIT PO Box 30199
    State of Michigan                                                                                     Lansing, MI 48909-7699
                                                                                                    TO
(i) Department of Treasury
    1. Date1. Date                       2. Account Number2. Account Number

    Fill in all requested information.
    Be sure the listed items are entered.
    3. Name

    4. Address
                                                                                                   6. Amount of Your Payment6. Amount of Your Payment
    5. City                                                 State                          ZIP Code
                                                                                                   $
                                                                                                   Make your  check payable  to "State  of
    PLEASE RETURN THIS WITH FORM 990, INSTALLMENT AGREEMENT.                                       Michigan - OC" and remit to above address.

- 3 -

Instructions for Completing Form 990,
Installment Agreement

Carefully read and complete the highlighted portions of the Installment Agreement form.

Treasury Account Number: Enter your Treasury Important Information
Account Number. The account number can be found in
Mail your first payment, in the amount proposed with
the upper right hand corner of your notice. Your account
your completed Installment Agreement and payment
number will begin with an “F” or an “S.”
coupon. If you elect to pay via Electronic Funds
Name and Address: Enter your complete name and Transfer mail completed form with your application.
address. Include your first, last and middle name
Approved Agreements
or entire business name. Enter your complete street
address. Payment coupons will be mailed for future payments.
If you have not received your payment coupons prior
Type of Entity: If applicable, check the type of entity.
to the next due date please write your assessment
For Driver Responsibility Fees the appropriate box to
number in the “memo” portion of your check, make
mark is “Individual.”
your check payable to the State of Michigan - CD, and
Home Telephone Number: Enter your home telephone
mail your payment to:
number, including area code.
Michigan Department of Treasury
Business Telephone Number: Enter your work
PO Box 30199
telephone number, including area code, or a number
Lansing MI 48909
where you can be reached Monday through Friday
between the hours of 8 a.m. and 5 p.m. Extra Payments
Assessment Number: Enter your assessment number(s). You may make extra payments on your balance.
The assessment number(s) can be found on your notice. However, we must receive a timely payment in the
If you are unsure of your total balance, enter the total agreed upon amount by the due date. Be sure to include
amount shown on your most recent notice. a payment coupon or a copy of your payment coupon
with your payment. Checks and money orders must
If a business, enter information about all owners,
have your assessment number/account number printed
partners, officers, major shareholders, etc.
in the “memo” portion to ensure proper credit on your
Proposed monthly payments/Proposed bi-weekly
account.
payments: Enter the proposed monthly or bi-weekly
payment. Use whole dollar amounts, do not enter Rejected Installment Agreement Applications
cents. Round up to the next dollar amount. Enter your If you are not approved for an installment arrangement
preferred payment due date. For Driver Responsibility you will receive a notice. Upon notification, you can
Fees, your payment arrangement may not exceed 24 contact the number listed on the notice or pay your
months. balance in full.
Signature Required: Sign document, enter your
Social Security number and today’s date. A signature
is required to process your request for an installment
agreement. If the debt is a joint debt, your spouse must
sign in the Spouse Signature field.
Bank Name and Address: Enter the name and address
of your bank/financial institution.
Employer Name and Address: Enter your employer’s
name and address.

- 4 -

Michigan Department of Treasury
3189 (Rev. 08-17)
Collection Information Statement – Individual
Issued under authority of Public Act 122 of 1941.
Complete  the  form,  sign  on  page  3,  and  include  any  required  documentation.  If  self-employed,  a  current  profit  and  loss  income 
statement must be included.
Part 1: PerSonal and houSehold InformatIon
Primary Taxpayer’s First Name          M.I.      Last Name                                              Account Number

Home Address                                                             City                                                                  State ZIP Code
                                                                          
Mailing Address (if different from above or Post Office Box number)      City                                                                  State ZIP Code
                                                                          
Place of Residence (Check the one that applies):                                                                                Marital Status           Age
Own your home                  Rent              Other (shared rent, living w/ relative, etc. -- include letter of explanation) Single         Married
Primary Telephone Number                              Secondary Telephone Number                        Fax Number

InformatIon about your SPouSe
Spouse’s First Name                    M.I.      Last Name                                              Social Security Number / Account Number Age

houSehold InformatIon
Total Number of People in Household                   Number of People Claimed as Dependents on MI-1040 Number of People Contributing to Household Resources

Household resources include all income (taxable and nontaxable) received by all adult household members during the year, including income that might 
be exempt from federal adjusted gross income. Attach an explanation of circumstances if necessary.
Part 2: emPloyment InformatIon
Attach copies of the three most recent pay stubs, earnings statements, etc., from each employer.
Primary Taxpayer’s Employer’s Name                                                Employer’s Telephone Number                                  Do you have an ownership 
                                                                                                                                               interest in this business?
Occupation                                                 Pay Frequency          Length of Employment with Employer                                 Yes     No
                                                                                                        (years)                 (months)
Employer’s Address                                                       City                                                                  State ZIP Code
                                                                          
Spouse’s Employer’s Name                                                          Spouse’s Employer’s Telephone Number                         Does spouse have ownership 
                                                                                                                                               interest in this business?
Spouse’s Occupation                                        Spouse’s Pay Frequency Length of Employment with Employer                                 Yes     No
                                                                                                        (years)                 (months)
Spouse’s Employer’s Address                                              City                                                                  State ZIP Code
                                                                          
Part 3: PerSonal aSSet InformatIon (InCludIng SPouSe)
Use the most recent statement for each type of account, such as checking, savings, money market and online accounts,  and stored value cards (e.g. a 
payroll card from an employer). Asset value is subject to adjustment by the Michigan Department of Treasury based on individual circumstances. Enter 
the total amount available for each of the following (if additional space is needed include attachments). note: Any monthly loan payment should be 
reflected on line 5i of Part 4: Monthly Household Expense Information.
CaSh and InveStmentS (domeStIC and foreIgn)
Type of Account
Checking                       Savings                 Money Market / CD         Online Account                 Stored Value Card                    Cash
Financial Institution Name                                                                              Value

Type of Account
Checking                       Savings                 Money Market / CD         Online Account                 Stored Value Card                    Cash
Financial Institution Name                                                                              Value

If attaching a separate sheet listing additional bank accounts, record the total of those accounts here.

                                                                                                                                                     Continue on Page 2

- 5 -

Form 3189, Page 2                                                                                                 Account Number

Part 4: monthly houSehold exPenSe InformatIon
Total allowable monthly expenses are calculated using the collection financial standards for the Michigan Department of Treasury for: housing and 
utilities; transportation; medical; food and clothing; minimum installment payments; and childcare and education.
Attach  copies  of  the  most  recent  statement  from  lender(s)  on  loans  such  as  mortgages,  second  mortgages,  vehicles,  etc.,  showing  minimum 
monthly payments, loan payoffs, and balances. Attach current billing statements showing total balance due and current payment due for all other 
expenses claimed.
1. housing and utilities
  1a. Mortgage (if paying more than one mortgage, provide proof for 
      all mortgages.) Enter the total of all payments here. .....................                           1a.
  1b. Rent ...............................................................................................  1b.
  1c. Property Taxes (if not included in mortgage) .....................................                    1c.
  1d. Homeowner’s/Renter’s Insurance (if not included in mortgage) ....... 1d.
  1e. Utilities .............................................................................................. 1e.
  1f. Telephone/Cell Phone/Cable TV/Internet ......................................... 1f.
  1g. Association Dues .............................................................................. 1g.
  1h.total housing and utilities. add lines 1a through 1g ................................................................................ 1h.
2. transportation — Number of Household Vehicles Owned                                                      2.
  2a. Ownership (provide a copy of the lease/loan agreement) ................ 2a.
  2b. Operating Costs (including maintenance, repairs, insurance, fuel, 
      registrations, licenses, inspections, parking, and tolls)..................... 2b.
  2c. Public Transportation ........................................................................ 2c.
2d.total transportation. add lines 2a through 2c ..........................................................................................2d.
3. out-of-Pocket Insurance/medical Costs
  3a. Health Insurance .............................................................................. 3a.
  3b. Life Insurance ................................................................................... 3b.
  3c. Medical Expenses ............................................................................ 3c.
3d.total Insurance/medical Costs. add lines 3a through 3c .........................................................................        3d.
4. food and Clothing
  4a. Groceries .......................................................................................... 4a.
  4b. Personal (apparel, services, and personal care products) ............... 4b.
  4c.total food and Clothing. add lines 4a through 4b .................................................................................... 4c.
5. Installment Payments — Provide current billing statements as proof for all items in lines 5a-5i.
  5a. Child Support ....................................................................................    5a.
  5b. Alimony ............................................................................................. 5b.
  5c. Garnishment .....................................................................................     5c.
  5d. Other Delinquent Taxes ....................................................................           5d.
  5e. 401(k) Loan Repayment ...................................................................             5e.
  5f. Credit Cards .....................................................................................    5f.
  5g. Union Dues/Employment Cost .........................................................                  5g.
  5h. Student Loans ..................................................................................      5h.
  5i. Other Monthly Installment Payments................................................                    5i.
  5j. total Installment Payments. add lines 5a through 5i ................................................................................ 5j.
6. Childcare and education — Provide current billing statements as proof for all items in lines 6a and 6b.
  6a. Childcare .......................................................................................... 6a.
  6b. Tuition/Education .............................................................................. 6b.
  6c. total Childcare and education. add lines 6a and 6b ................................................................................  6c.
7. total monthly household expenses.         Add lines 1h, 2d, 3d, 4c, 5j, and 6c ..............................................           7.
                                                                                                                                              Continue on Page 3

- 6 -

Form 3189, Page 3 Account Number

Part 5: monthly houSehold reSourCeS InformatIon
Total household resources include all income (taxable and nontaxable) received by all adult household members during the year, including income that
might be exempt from federal adjusted gross income. Net losses from business activity may not be used to reduce total household resources. This
information is necessary for the Michigan Department of Treasury to accurately evaluate your circumstances.
Attach copies of the most recent statements from all other sources of income such as pensions, Social Security, rental income, interest and dividends
(including any received from a related partnership, corporation, LLC, LLP, etc.), court order for child support, alimony, and rent subsidies.
Self-employed taxpayers: Complete line 3d based on a current profit and loss statement. Include that statement with this form.
1. Primary taxpayer’s Income
1a. Wages (attach copies of the three most recent pay stubs) ............. 1a.
1b. Social Security (including Disability and Social Security income) ... 1b.
1c. Pension(s)/Other Retirement Distribution ........................................ 1c.
1d. Unemployment ................................................................................ 1d.
1e. Government Assistance (cash/food)................................................ 1e.
1f. Vendor Payments from the State of Michigan ................................. 1f.
1g. Other Income (attach an explanation) ............................................. 1g.
1h. total Primary taxpayer’s Income. add lines 1a through 1g. ................................................................... 1h.
2. Spouse’s Income
2a. Wages (attach copies of the three most recent pay stubs) ............. 2a.
2b. Social Security (including Disability and Social Security income) ... 2b.
2c. Pension(s)/Other Retirement Distribution ........................................ 2c.
2d. Unemployment ................................................................................ 2d.
2e. Government Assistance (cash/food)................................................ 2e.
2f. Vendor Payments from the State of Michigan ................................. 2f.
2g. Other Income (attach an explanation) ............................................. 2g.
2h. total Spouse’s Income. add lines 2a through 2g ..................................................................................... 2h.
3. other household Income
3a. Interest and Dividends ..................................................................... 3a.
3b. Distributions (income from partnerships, S corporations, etc.) ........ 3b.
3c. Rental Income ................................................................................. 3c.
3d. Net Business Income (attach most recent profit and loss statement) 3d.
3e. Combined Child Support Received ................................................. 3e.
3f. Alimony Received ............................................................................ 3f.
3g. Additional Sources of Income - not accounted for elsewhere on this
form (attach an explanation) ............................................................ 3g.
3h. total other household Income. add lines 3a through 3g. ....................................................................... 3h.
4. total monthly household Income. add lines 1h, 2h, and 3h. .................................................................. 4.

Part 6: CertIfICatIon
Under penalty of perjury, I declare that I have examined this information, including accompanying documents, and certify to the best of my knowledge
and belief, it is true, correct, and complete.
Primary Taxpayer’s Signature Date

Spouse’s Signature Date

Authorized Representative’s Signature Date

Authorized Representative’s Name (Print or Type) Title/Position Telephone Number

note: Attach an Authorized Representative Declaration (Power of Attorney) (Form 151) to designate a third party representative.

PDF file checksum: 63314397

(Plugin #1/9.12/13.0)