Offer In Compromise Application (Continued) Form - California Franchise Tax Board

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State of California — Franchise Tax Board
Offer in Compromise Application (Continued)
Date
Name of Business Entity
California Business Number
Address
Telephone Number
Name and Address of primary contact
Federal Employer ID Number (FEIN)
Telephone Number (
)
Title
Assumer’s Name and Address
California or Federal Identification
Number
Telephone Number (
)
Authorized representative (attach Power of Attorney)
Address
Telephone Number (
)
The undersigned submits this Offer in Compromise for payment of the California state tax liability shown below:
1. AMOUNT OWED
Tax Year(s)____________________________________________________
Amount Due __________________________________________________
Include tax, interest, and penalties.)
2. OFFER
The sum of $ ________________________________ is offered in compromise. We will instruct you when to pay
the the offer amount. Do not send any funds now.
If this Offer in Compromise is denied, the Franchise Tax Board is to:
__________ Retain any amounts deposited and credit it to the undersigned’s liabilities.
__________ Return the amount deposited.
4
FTB 4905BE C1 (NEW 05-2007)

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