HomeMy WebLinkAboutHCTAT - RIPA (Request for an Installment Plan Agreement)HCTAT-RIPA
HCTAT-RIPA
County of Hawaii
Department of Finance TAT Office
25 Aupuni St., STE 1101
Hilo, HI 96720
(808) 961-8793
REQUEST FOR AN INSTALLMENT PLAN AGREEMENT
Taxpayer Name: ____________________________________________________________________________
DBA Name: ________________________________________________________________________________
TA Number: TA - __ __ __ - __ __ __ - __ __ __ __ - __ __
Mailing Address: ____________________________________________________________________________ (STREET) (CITY) (STATE) (ZIP)
Phone Number: ( ) _____________________________ ☐ Home ☐ Cell ☐ Work
Place of employment: ________________________________ Monthly gross income: _____________
Spouse’s Place of employment: _______________________ Monthly gross income: _____________
Do you own real property? ☐ Yes ☐ No If yes, where is it located: _________________________ (City/State or Country)
Household size: ______________________ Amount you can pay a month: _________________________
Do you currently have an installment plan with the State of Hawaii Department of Taxation? ☐ Yes ☐ No
In the area provided below, please give a detailed explanation for your request, along with any
supporting facts. You may use a separate sheet of paper or a letter if necessary. Be sure to attach
any relevant documentation supporting your request for an Installment Plan/Agreement. (Please
print or write legibly in blue or black ink). PLEASE ALLOW APPROXIMATELY 4-6 WEEKS TO
PROCESS THIS REQUEST. REQUESTS MAY TAKE LONGER DURING PEAK COLLECTION PERIODS.
Signature: __________________________________________________________________________________
By signing this form, I attest under penalty of perjury that the above information is true and correct.
HCTAT INTERNAL USE ONLY
☐ Approved ☐ Denied
Penalty: ____________________ Interest: ____________________ Total Waived: ___________________________
Reason for denial: ______________________________________________________________________________________
Division Head: ___________________________________ Director: ________________________________________