Kentucky Kentucky Individual Income Tax Installment Agreement Request

Kentucky Individual Income Tax Installment Agreement Request
Form 12A200
GENERAL INSTRUCTIONS
If you are unable to pay the full amount due with your individual income tax return, you may request an installment agreement
by completing this form and mailing it to: Division of Collections, P. O. Box 491, Frankfort, Kentucky 40602-0491. Specify the
amount of the monthly payment you propose to make in the block marked “Proposed Monthly Payment Amount.” Payments
should be as large as possible to lower penalty and interest charges. Requested Installment Agreements must be created
by the Division of Collections after a tax notice has been issued.
You can make installment payments in three ways. Credit cards or ACH Debits will save you the time and trouble of mailing
monthly payments and may help save you additional penalties, interest or fees.
•	

Pay by ACH Debit—To request that your monthly payments be withdrawn electronically from a bank account,
enclose a voided check with the completed form below. You may also call (502) 564-4921, ext. 5354 to request
this option. Please indicate date for ACH Debit payment.

•	

Pay by Mail—Make your checks or money orders payable to the Kentucky State Treasurer. Include the taxpayer’s
full name(s), Social Security number(s), and the tax period you are paying. Mail the payments to the Division of
Collections, P.O. Box 491, Frankfort, KY 40602-0491.

You will be advised if your request for an installment agreement is approved or denied. If you do not receive a response to this
request within 90 days from the date you file your return, please call the Division of Collections, (502) 564-4921, ext. 5354.



CUT HERE
MAIL THIS FORM TO THE DIVISION OF COLLECTIONS

12A200 (11-23)
DEPARTMENT OF REVENUE

Taxpayer full name(s) as shown on return	

Taxpayer Social Security number	

Address	

City	

Home telephone number	

Convenient time to call

(   )
Amount paid with return	

Amount you owe (Form 740, Form 740-NP)

$	$

	

2 0 _ _

KENTUCKY INDIVIDUAL INCOME TAX
INSTALLMENT AGREEMENT REQUEST

Spouse Social Security number

State	

ZIP Code

	 Pay by ACH		
  Check if paying by ACH Debit
	Debit/Electronic		 (Attach voided check)
	Check  	 
PROPOSED MONTHLY PAYMENT AMOUNT
	 Amount I am able to pay each month	

$

	 Date of first payment	

Date each month I am able to pay

Page 1 of 2

INDIVIDUAL INCOME TAX
INSTALLMENT AGREEMENT REQUEST
GENERAL INFORMATION

A Kentucky taxpayer has the right to consideration of an
installment agreement for the payment of delinquent taxes,
interest, penalties and fees. The right to an installment
agreement is provided for in KRS 131.081(9) and is
primarily dependent on the taxpayer’s inability to pay the
amount due in full.
Eligibility for an Installment Agreement
An installment agreement should be requested only
when there is no other way of paying the liability on
time and in full.
A taxpayer must clearly demonstrate an inability to pay the
liability in full and the agreement must facilitate collection.
Generally this means that taxpayers who have the ability
to pay with available funds or borrow from a financial
institution are not eligible.
Proposed Monthly Payment Amount
The monthly payment amount will be based upon the
taxpayer’s ability to pay after considering the taxpayer’s
monthly income and reasonable expenses. Allowable
expenses generally include reasonable amounts for food,
clothing, housing (and associated expenses), installment
payments and other necessary living expenses. The
proposed monthly payment amount should be as much as
possible to minimize the length of the agreement and the
accrual of interest, penalties and fees.
Interest, Penalties, Fees and Refund Offsets
The law provides for the assessment of interest, penalties
and fees for tax liabilities paid after the due date. Interest
accrues at the tax interest rate (11 percent for 2024).
In addition, penalties of 2 percent per month may be
assessed on the unpaid tax. A 25 percent Cost of Collection
Fee is imposed on tax due which becomes due and
payable (generally 61 days after the assessment date).
Interest, penalties and fees continue to accumulate while
an installment agreement is in place. Also, any money
Kentucky may owe you (tax refunds, etc.) will be offset to
your outstanding liability. Additionally, any federal income
tax refund that may become due to you may be offset to
this liability pursuant to 26 USC §6402(e).

Page 2 of 2

Setting up the Agreement
Taxpayers who believe they qualify for an installment
agreement should complete Form 12A200, Individual
Income Tax Installment Agreement Request, and mail it
to the Division of Collections, P. O. Box 491, Frankfort,
Kentucky 40602-0491.
State Tax Lien
Depending on the amount and length of the agreement, a
State Tax Lien may be filed. If a lien is filed, it will remain
on the taxpayer’s credit record for up to seven years after
the liability is paid and the lien is released.
Assistance
Questions should be directed to:
Division of Collections
Kentucky Department of Revenue
P.O. Box 491
Frankfort, KY 40602-0491
(502) 564-4921, ext. 5354
Form 12A 200, Individual Income Tax Installment
Agreement Request, is available at Kentucky Taxpayer
Service Centers located throughout the Commonwealth.
Forms may also be obtained from the Internet at
revenue.ky.gov, or by contacting the Division of
Collections or by sending a written request to:
FORMS
Kentucky Department of Revenue
501 High Street, Station 23B
Frankfort, KY 40601
(502) 564-3658