Ro 1033 Form – Fill Out and Use This PDF

RO-1033Installment Agreement Request

	Web	North Carolina Department of Revenue
	3-15

Please print legibly using all capital letters in blue or black ink.

Individual’s First Name

M.I.

Individual’s Last Name

Individual’s Social Security Number

Spouse’s First Name (If joint liability)

M.I.

Spouse’s Last Name (If

joint liability)

Spouse’s Social Security Number (If joint liability)

Entity’s Legal Name (If Corporation)

Federal Employer ID Number

Daytime Telephone Number (Include area code.)

Home Telephone Number (Include area code.)

If Joint, Spouse’s Daytime Telephone Number

ADDRESS

County (Enter irst ive letters)

City

State

Zip Code

Country (If not U.S.)

Part 1. Installment Request

4.Payment Frequency

If date falls on a weekend or holiday, the transfer will occur on the next business day.

Fill in applicable circle:

Monthly	Weekly (Please ill in corresponding day, i.e. MO, TU, WE, TH, FR.
2 x Month (1st and 15th ONLY)	Day must correspond with the irst installment date.)

Part 2. Bank Account Information

(Approved agreements must be paid in monthly or semimonthly installments by direct transfer from your bank account.)

5. Financial Institution Name

6. Account Type

7. Transit or Routing Number 8. Bank Account Number

Fill in applicable circle:

Personal Checking

Personal Savings

Business Checking

Business Savings

Part 3. Authorized Signature

(The Installment Agreement must be signed by the taxpayer or an individual authorized to act on behalf of the taxpayer. Generally, this is the person with the authority to sign a tax return.)

I certify that I have the authority to request an electronic debit from the account named above, and I authorize the N.C. Department of Revenue to present debit entries for the bank account and the inancial institution named above. This authorization will remain in effect until the balance due has been paid, the N.C. Department of Revenue cancels the installment agreement, or a written notiication from the taxpayer to stop the debit transactions has been received and processed. The N.C. Department of Revenue may cancel the installment agreement and charge the taxpayer a dishonored payment penalty and a collection fee if the monthly payment cannot be deducted due to insuficient funds or because the account is closed. The taxpayer will be responsible for any overdraft fees charged by the bank.

If this request is accepted by the N.C. Department of Revenue and an installment agreement is established, the following conditions apply: The agreement is based on the taxpayer’s current inancial circumstances and is subject to revision or termination if subsequent inancial information required by the N.C. Department of Revenue relects a change in the taxpayer’s ability to pay. Failure to provide updated inancial information when requested by the N.C. Department of Revenue will be reason for termination of the agreement. All State taxes and all State returns that become due during the term of the agreement must be iled on time. Any State or Federal refunds that might otherwise be due may be applied to this liability until it is satisied. If the conditions of this installment agreement are not met, it will be terminated, and the entire tax liability will be due. The agreement may be terminated if collection of the tax liability is in jeopardy. This request may require managerial approval; you will be notiied if it is not approved. If you are granted an installment agreement and subsequently default on that agreement, you will NOT be eligible for another installment agreement with the N.C. Department of Revenue.

Authorized Signature

Print Name

Title (if business)

Date

If you have any questions about your installment agreement request, call toll free 1 (877) 252-3252. An Interactive Voice Response System is available at all times. Our representatives are available weekdays from 8:00 a.m. to 5:00 p.m.

MAIL TO: Central Collection Unit, 1500 Pinecroft Rd Ste 300, Greensboro, North Carolina 27407-3808 or Fax to: 1 (336) 218-5711