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4868 Form
4868
Step
1
of
2
50%
Email
*
Tax Year
2022
2021
Do you want to apply extension for other tax year?
Yes
No
Start Date
DD dot MM dot YYYY
End Date
DD dot MM dot YYYY
Part 1: Identification
1. Your Name (s)
Address
Address (Number and Street)
City, town, or post office
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP code
2. Social Security Number
3. Spouse’s Social Security Number
Part 2: Individual Income Tax
4. Estimate of total tax liability for this tax year
5. Total payments this tax year
7. Amount you’re paying
8. Check here if you’re “out of the country” and a U.S. citizen or resident
9. Check here if you file Form 1040-NR and didn’t receive wages as an employee subject to U.S. income tax withholding
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4868 Form
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Card Number
Expiration Date
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Cardholder Name
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