2
Form 9465 (Rev. 12-2013)
Page
Part II
Additional information. Complete this part only if you have defaulted on an installment agreement within the
past 12 months and the amount you owe is greater than $25,000 but not more $50,000 and the amount on
line 10 is equal to or greater than the amount on line 11. If you owe more than $50,000, complete and attach
Form 433-F, Collection Information Statement.
15
In which county is your primary residence?
16a Marital status:
Single. Skip question 16b and go to question 17.
Married. Go to question 16b.
b Do you share household expenses with your spouse?
Yes.
No.
17
17
How many dependents will you be able to claim on this year's tax return?.
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18
How many people in your household are 65 or older?
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18
19
How often are you paid?
Once a week.
Once every two weeks.
Once a month.
Twice a month.
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20
What is your net income per pay period (take home pay)? .
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20
21
How often is your spouse paid?
Once a week.
Once every two weeks.
Once a month.
Twice a month.
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22
What is your spouse's net income per pay period (take home pay)? .
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22
23
How many vehicles do you own? .
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23
24
How many car payments do you have each month? . . . . . . . . . . . . . . . . . . .
24
25a Do you have health insurance?
Yes. Go to question 25b.
No. Skip question 25b and go to question 26a.
b Are your premiums deducted from your paycheck?
Yes. Skip question 25c and go to question 26a.
No. Go to question 25c.
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c How much are your monthly premiums?
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25c
26a Do you make court-ordered payments?
Yes. Go to question 26b.
No. Go to question 27.
b Are your court-ordered payments deducted from your paycheck?
Yes. Go to question 27.
No. Go to question 26c.
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c How much are your court-ordered payments each month?
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26c
27
Not including any court-ordered payments for child and dependent support, how much do you pay
for child or dependent care each month?
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9465
Form
(Rev. 12-2013)