Form 656 - Offer In Compromise Page 2
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Section 3
Reason for Offer
(Continued)
Explanation of Circumstances (Add additional pages, if needed)
The IRS understands that there are unplanned events or special circumstances, such as serious illness, where paying the full amount or the minimum
offer amount might impair your ability to provide for yourself and your family. If this is the case and you can provide documentation to prove your
situation, then your offer may be accepted despite your financial profile. Describe your situation below and attach appropriate documents to this offer
application.
Section 4
Low Income Certification
(Individuals Only)
Do you qualify for Low-Income Certification? You qualify if your gross monthly household income is less than or equal to the amount shown in the
chart below based on your family size and where you live. If you qualify, you are not required to submit any payments during the consideration of your
offer.
Check here if you qualify for Low-Income Certification based on the monthly income guidelines below.
Size of family unit
48 contiguous states and D.C.
Hawaii
Alaska
1
$2,256
$2,596
$2,819
2
$3,035
$3,492
$3,794
3
$3,815
$4,388
$4,769
4
$4,594
$5,283
$5,744
5
$5,373
$6,179
$6,719
6
$6,152
$7,075
$7,694
7
$6,931
$7,971
$8,669
8
$7,710
$8,867
$9,644
For each additional person,
$ 779
$ 896
$ 975
add
Section 5
Payment Terms
Enter the amount of your offer $
Check one of the payment options below to indicate how long it will take you to pay your offer in full:
Payment Option 1
Check here if you will pay your offer in five or fewer payments:
Enclose a check for 20% of the offer amount (waived if you are an individual and met the requirements for Low-Income certification) and fill in the
amount(s) and date(s) of your future payment(s).
20% of the offer amount is $
leaving a balance of $
to be paid as follows after the acceptance of your offer:
Amount of payment 1 $
date
Amount of payment 2 $
date
Amount of payment 3 $
date
Amount of payment 4 $
date
Amount of payment 5 $
date
Payment Option 2
Check here if you will pay your offer in full in more than five months and pay in monthly installments
Enclose a check for one month's installment (waived if you are an individual and met the requirements for Low-Income certification)
$
is being submitted with the Form 656 and then $
on the
(day) of each month thereafter for a
total of
months. Total payments must equal the total Offer Amount.
You must continue to make these monthly payments while the IRS is considering the offer. Failure to make regular monthly payments
will cause your offer to be returned.
656
Catalog Number 16728N
Form
(Rev. 3-2011)
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