Payment Plan Request Form

Having trouble completing this form? Email the Division of Taxation at PaymentPlanUnit@treas.nj.gov for assistance.

Basic Information

Select your Language Value is not selected

I am requesting a payment plan for Value is not selected

First Name

Last Name

Spouse/Civil Union Partner First Name

Spouse/Civil Union Partner Last Name

Business Name

NJ Registration # / FEIN

Responsible Officer

Social Security Number

Primary Social Security Number This is usually yours but could be your partner's if they are listed first on tax forms. We also accept Taxpayer ID Numbers (ITIN).

Secondary Social Security Number If you filed with your partner, please include their SSN/ITIN.

Unmasked Primary SSN

Unmasked Secondary SSN

Email

Address

Physical Address of Business

Is the physical address the same as the mailing address?

Mailing Address

Address

Address line 2 Please enter your apartment, suite, or building number here.

City

State Value is not selected

Zip

Primary Phone Number

Secondary Phone Number

Cigarette Tax Invoice #

Does your business owe trust fund taxes (sales tax, employee payroll tax, etc.)?

Yes

No

Responsible Person Acknowledgement and Judgment Authorization

A responsible person may be any officer or employee of any entity other than a sole proprietorship who is under the duty to collect and remit trust fund taxes and personal liability taxes* to the State of New Jersey on behalf of the entity. A responsible person may be held personally liable for any of these taxes due from the entity.

*This includes: Sales & Use Tax, Gross Income Withholding Tax, Motor Fuels Tax, 9-1-1 Emergency Response Fee, Atlantic City Luxury Tax, Cape May Tourism Tax, Hotels/Motels State Occupancy Fee and Municipal Occupancy Tax, Motor Vehicle Tire Fee, and Tobacco and Nicotine Products Wholesale Sales and Use Tax.

Please check the factors that apply to you: I understand there is no set number which qualifies me as a responsible person. I will check all appropriate boxes. By signing my name below, I am acknowledging I am in fact a responsible person for the business shown for the tax periods designated. I am also acknowledging that I have received and understand the terms of this authorization.

The contents of the corporate by-laws authorize you to act on behalf of the business.

Status as an officer and/or stockholder.

Authority to sign checks and exercise of this authority.

Authority to hire and fire and exercise of this authority.

Responsibility to prepare and/or sign tax returns.

Day-to-day involvement in the business or responsibility for management.

Power to control payment of corporate creditors and taxes.

Knowledge of failure to remit taxes when due.

Derivation of substantial income or benefits from the corporation.

Tax Value is not selected

From: Tax period(s) to be included in this plan.

To: Tax period(s) to be included in this plan.

What was the effective date you became a responsible officer of the business?

Payment Information

Balance Due Please include all unpaid balances. If you're unsure how much you owe, please estimate to the best of your ability.

HIDDEN - Case statement for Balance Due

Requested Monthly Payment Payment amount must be at least $25 and standard plans may be approved up to 60 months. Please note that monthly payment amount is subject to adjustment and approval by the Division of Taxation.

HIDDEN - Case statement for monthly payment

HIDDEN - No Change allowed

Preferred Monthly Due Date Valid dates are the 1st through the 28th. Value is not selected

Full Name

Signature

I affirmatively request that the New Jersey Division of Taxation forgo the 30/90 day demand period and file judgment against me for the non-judgmented portion of my trust tax liability.

I further understand that Certificates of Debt may be entered against me personally as well as my business in order to protect the State and secure payment of the debt.

I declare this Responsible Person Acknowledgement, which examined to the best of my knowledge and belief is true and correct.

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Tax - 00001 - Taxpayer Payment Plans

Payment Plan Request Form

Basic Information

Responsible Person Acknowledgement and Judgment Authorization

Payment Information

Signature