Ount Number FEIN (If Applicable) Business Mailing Address (number and street) Unit Type City State Unit Number ZIP Applicant(s) Legal Structure Sole Proprietorship Partnership Corporation Trust/Estate Contact Name LLC Contact Phone Email Address Name of Bank Bank Account Number Bank Routing Number Description of Tax Type To Be INCLUDED in the Installment Request (Mark and complete all that apply.) Tax Type Filing Period(s) Amount Due Employer Withholding Tax LDR Account Number.

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