Utah Individual Income Tax Payment Agreement Request

Individual Income Tax Payment Agreement Request
TC-804, Individual Income Tax Payment Agreement Request
Clear form
Utah State Tax Commission

Individual Income Tax
Payment Agreement Request

TC-804
Rev. 1/19

Get forms at tax.utah.gov/forms

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
Full name (first, middle, last)

Social Security number

If a joint return, spouse’s full name (first, middle, last)

Spouse’s Social Security number

Address

Daytime telephone number

Evening telephone number

Email address (required for pay plan reminders)

Employer(s) name, address and telephone number

Spouse’s employer(s) name, address and telephone number

TIP: If you are submitting this form in response to a billing notice, do not complete lines 1 through 3. Instead, attach the bottom section
of the billing notice to this form and complete lines 4 through 6.
1.

Enter the income tax year for which you are making this request (example, “2011”) –––––––––––––

2.

Enter the total amount you owe as shown on your income tax return –––––––––––––––––––––––– $

3.

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.

4.

Enter the amount you can pay each month. Your payment should be large enough to pay off –––––
the tax due, penalty and interest within 24 months. 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 incometax.utah.gov.

5.

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.

6.

You must have filed income tax returns for all prior years before your pay plan will be approved.
If you have not, list the year(s) 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.
Signature

Date

Spouse’s signature (if joint return, both must sign)

If you need an accommodation under the Americans with Disabilities Act, email [email protected],
or call 801-297-3811 or TDD 801-297- 2020. Please allow three working days for a response.

Date

Purpose of Form
Use this form to request a monthly payment plan if you
cannot pay the full amount you owe on your individual
income tax return (or on a billing notice we sent you).
Generally, you may have up to 24 months to pay.
However, it is better to pay the amount you owe as
soon as you can to reduce the amount of interest you
will pay.
NOTE: A payment plan for business taxes is requested
on form TC-804B.
Bankruptcy
If you are in bankruptcy do not use this form. Instead,
call 801-297-6219 or if you are out of the Salt Lake
area 1-800-662-4335 ext. 6219.
How Does the Agreement Process Work?
If your request is approved, we will send you an email.
The email will confirm your monthly payment amount
and the number of required payments. It will also
explain how to make your first payment. You will have
the following payment options:
1. Pay by mail with check or money order.
2. Pay in person at one of our offices.
3. Pay by Internet at tap.utah.gov.
a. Electronic check (direct debit) from your
checking or savings account.
b. Credit card (American Express, Discover
Card, MasterCard and Visa). You will be
charged a fee each time you use this
method of payment. The fee is based on a
percentage of the payment made.
By approving your request we agree to let you pay the
tax you owe in monthly payments instead of immediately paying the tax in full. In return you agree to make
your monthly payments on time. You also agree to
meet all of your future tax liabilities. This means that
you must have enough withholding or prepayments so
that your future tax liability is paid in full when you file a
timely return.
Any future year refunds due you from the Internal
Revenue Service or the State will be applied against
the amount you owe.
Important Note: Failure to make your payments on
time or failure to file and/or pay future returns when
due, will break your payment agreement. If you break
the agreement we can take action to collect the tax you
owe in full and place liens on your real and tangible
personal property.

Form Instructions
If you are making this request for a joint filed return,
enter the names and Social Security numbers in the
same order as they appear on your tax return, your
telephone numbers and email address.
Line 3
Enter any payment amount being paid with the return
or billing notice. Pay as much as possible to lower the
amount of penalty and interest you will be assessed.
Line 4
Enter the amount you can pay monthly. Even if you
cannot pay the full amount you owe now, pay as much
as possible each month to lower the amount of penalty
and interest you will be assessed.
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
incometax.utah.gov.
Line 5
Enter the day of the month you want the payment due.
This is the day the payment must be received by the
Tax Commission. Note: If you are mailing your
payment, allow 3 to 5 days for mail delivery.
Line 6
You must have filed a return for all prior years. List the
years for which you have not filed an income tax return.
If you are unable to file a return due to lost records you
need to estimate your liability. Your payment agreement
will not be approved until all returns have been filed. If
you have questions contact us at 801-297-7703.
Signatures
If you are filing a request for a joint filed return, the
signatures of both taxpayers are required.
Submit to:
Utah State Tax Commission
210 N 1950 W
SLC, UT 84134-7000
or fax form to: 801-297-6202
Email Address Note: All pay plan communication is
done through email. Include your email address where
indicated. The email address will be used to send you
notice of approval and to remind you of your pay plan.