Taxpayer Payment Agreement Request Form

2. Taxpayer First Name:
3. Taxpayer Last Name:
5. Tax Account Number(s):
7. Mailing Address
8. Physical Address
10. City
11. State
12. Zip
14. Phone Number:
15. Email Address:
17. Employer:
18. Bank:
20. Requested Monthly Payment Amount:

    Amount Taxpayer requests to pay each month until delinquent taxes are paid in full. Treasurer reserves the right to reject this requested amount. It is agreed that payments are to be made by the 30th day of each month beginning in the month following Taxpayer's enrollment in this Agreement and continuing until the full sum now due, plus any interest accruing, as provided by law is paid in full.

21. Today's Date:
    Today's Date:
23. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
25. Electronic Signature

    An Agreement Taxpayers may enter into to make payments each month on delinquent taxes owed to the County of Wise with the Treasurer of Wise County.

    Failure to make any scheduled payment by the due date shall cause this Agreement to be considered in default.  The Debtor agrees to timely file and to pay all taxes required by law under authority of the Code of Virginia and/or local ordinance which shall come due from this day forward, the failure to do so shall constitute default on this Agreement. 

    Taxpayer does hereby authorize and empower the Treasurer to appear for Taxpayer and to enter and confess judgment for the entire amount of this Agreement, with interest, less credits received, at any time after the same becomes due and payable, as herein provided; to waive the issuance and service of process upon the Taxpayer in any suit on the obligation; to release all errors which may intervene in entering upon such judgment or in issuing any execution thereon; and to consent to immediate execution on said judgment.

    Taxpayer hereby affirms under penalties of perjury that the information provided in this Agreement is true and correct.  The Taxpayer does hereby certify that they have read and understand the terms set forth in this Agreement.  The Treasurer of Wise County reserves the right to terminate this agreement at any time for any cause. 

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27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

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