Free Form 13844 (Rev. 1-2009) - Federal

Form 13844 (January 2009)

Department of the Treasury -- Internal Revenue Service

Application For Reduced User Fee For Installment Agreements

The user fee for entering into an installment agreement after January 1, 2007 may be reduced to $43 for individuals whose income falls below 250% of the dollar criteria established by the poverty guidelines updated annually by the U.S. Department of Health and Human Services. The reduced user fee for individuals with incomes below these levels does not apply to corporations or partnerships. Use this form to apply for the reduced user fee. If your application is granted, the amount of any user fee collected in excess of $43 will be applied against your Internal Revenue Code liabilities and thereby reduce the amount of interest and penalties that may otherwise accrue. To request the reduced user fee, mail this form to: IRS, P.O. Box 219236, Stop 5050, Kansas City, MO 64121-9236. If you are an individual, follow the steps below to determine if you qualify for a reduced installment agreement user fee. 1. Family Unit Size . Enter the total number of dependents (including yourself and your spouse) claimed on your current income tax return (Form 1040, Line 6d). 2. Total Income . Enter the amount of total income reported on your current income tax return (Form 1040, Line 22). 3. Compare the information you entered in items 1 and 2, above, to the Reduced User Fee Income Guidelines table below. Find the "Size of Family Unit" equal to the number you entered in item 1. Next, find the column which represents where you reside (48 Contiguous States and DC ..., Alaska or Hawaii). Compare the Total Income you entered in item 2 to the number in the row and column that corresponds to your family unit size and residence. For example, if you reside in one of the 48 contiguous states, and your family unit size from item 1 above is 4, and your Total Income from item 2 above is $50,000, then you are qualified for a reduction of the installment agreement user fee because your income is less than the $53,000 guideline amount. 4. If the total income you entered in item 2 is more than the amount shown for your family unit size and residence in the Reduced User Fee Income Guidelines table below, you do not qualify for a reduction of the installment agreement user fee. 5. If the total income you entered in item 2 is equal to or less than the amount shown for your family unit size and residence in the Reduced User Fee Income Guidelines table below, you may qualify for a reduction of the installment agreement user fee. If you qualify for a reduction of the user fee based on your income level, you must sign and date the certification portion of this form and submit it to the IRS within 30 days from the date of the Installment Agreement acceptance letter that you received. Applications submitted after the due date will not be considered for qualification.
Reduced User Fee Income Guidelines Size of Family Unit 1 2 3 4 5 6 7 8 For each additional person, add 48 Contiguous States and D.C. $26,000 $35,000 $44,000 $53,000 $62,000 $71,000 $80,000 $89,000 $9,000 Alaska $32,500 $43,750 $55,000 $66,250 $77,500 $88,750 $100,000 $111,250 $11,250 Hawaii $29,900 $40,250 $50,600 $60,950 $71,300 $81,650 $92,000 $102,350 $10,350

Source: Based on 2008 US Dept of Health & Human Services Poverty Guidelines, Federal Register, Vol.73, No. 15, January 23, 2008, pp. 3971­3972 Your Name (Last, First, Middle Initial) (Please Print) Spouse's Name (Last, First, Middle Initial) (Please Print) Social Security Number (SSN) or Taxpayer Identification Number (TIN) Social Security Number (SSN) or Taxpayer Identification Number (TIN)

Certification: I certify under penalty of perjury that I am eligible for a reduction of the installment agreement user fee based on my family unit size and income.
Your Signature Spouse's Signature (if it is a joint liability) Catalog Number 49443R Date Date www.irs.gov Form 13844 (Rev. 1-2009)

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