Form 4868-Personal-Indiviual

Primary Taxpayer Information

Single or Joint Filing *

First Name*

Middle Name

Last Name*

Suffix*

SSN*

Day Time Phone Number*

Spouse Information (If Joint Filing)

Spouse First Name*

Spouse Middle Name

Spouse Last Name*

Spouse SSN*

Spouse Day Time Phone Number*

Mailing Address Information

Is Foreign Address? (Yes/No)*

US Address 1*

US Address 2

US City*

US State*

US Zip Code*

Foreign Address 1*

Foreign Address 2

Foreign City

Foreign State or Province*

Foreign Country*

Foreign ZIP or Postal Code*

Other Details

Select 'Yes' if the taxpayer is a US citizen or resident and qualifies for "Out of Country" status

Select 'Yes' if the taxpayer files 1040NR or 1040NR-EZ and does not receive a wage that is subject to income tax withholding

Tax Liability

Does the taxpayer owe taxes to the IRS? (Yes/No)*

Total Tax Liability For The Year (If 'Yes')*

Total Payments Made For The Year

Balance Due To The IRS

Amount to be paid to the IRS*

Payment Option

IRS Payment Option*

Account Details (Only if EFW is selected)

Account Type(If EFW is selected )*

Bank Account Number(If EFW is selected )*

Bank Routing Number(If EFW is selected )*

Primary Tax Payer's Day Time Phone(If EFW is selected )*

Electronic Signature (If EFW is selected)

Primary Tax Payer's 5 digit PIN *

Primary Tax Payer's Date of Birth*

Spouse 5 digit PIN (If joint filing)*

Spouse Date of Birth (If joint filing)*

Enter EITHER their Previous year's Adjusted Gross Income (AGI) OR their Previous year's PIN. (If EFW is selected)

Primary Tax Payer's Previous Year's (2022) AGI *

Primary Tax Payer's Previous year's PIN*

Spouse's Previous Year's (2022) AGI (If joint filing)*

Spouse's Previous year's PIN (If joint filing)*