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    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. 

    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.

                            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.