Form Ador 20-0001f - Offer-In-Compromise & Statement Of Offer 2009
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1OFFER-IN-COMPROMISE • STATEMENT OF OFFER
Arizona Department Of Revenue
Offer
TAXPAYER NAME(S), DBA, OR CORPORATE NAME
I/We offer to pay $________________ in lieu of the
above-mentioned liability.
I/We acknowledge that the
above liability is due and owing to the Arizona Department
of Revenue and request that the department abate the
remaining balance due pursuant to ARS §42-1004.B. By
STREET ADDRESS
submitting this Offer-in-Compromise, I/we understand and
agree to the terms and conditions on the reverse side of
CITY, STATE, ZIP CODE
this form.
Payment Terms
MAIL ADDRESS (if different from above)
Payment in full enclosed with this offer.
Payment in full within:
CITY, STATE, ZIP CODE
30,
60, or
90 days
from the date of acceptance of this offer.
What is the source of funds for your offer?
Individual Income Tax
YOUR SOCIAL SECURITY NUMBER
AMOUNT OWED
$
SPOUSE’S SOCIAL SECURITY NUMBER
Reason for Offer
Transaction Privilege Tax
Briefl y state your reason for making this offer. Include any
LICENSE NUMBER
AMOUNT OWED
information that you feel is pertinent to this offer:
$
Withholding Tax
LICENSE NUMBER
AMOUNT OWED
$
Federal Tax Information
Corporate Income Tax
TAX LIABILITY OWED TO THE INTERNAL REVENUE SERVICE (IRS)
LICENSE NUMBER
AMOUNT OWED
$
$
HAVE YOU SUBMITTED AN OFFER TO THE IRS?
Waste Tire Tax
Yes
No
LICENSE NUMBER
AMOUNT OWED
ARE YOU MAKING PAYMENTS TO THE IRS?
$
Yes
No
IF YES, AMOUNT OF MONTHLY PAYMENT
$
If you are submitting an Offer-in-Compromise for a business
Signature(s)
liability, please indicate the type of your organization:
I/We agree with the terms and conditions set forth in this
Sole Proprietorship
form. I/We have fully examined this offer and to the best
of my/our knowledge and belief, it is true, correct and
Partnership
complete.
Limited Partnership
Corporation:
SIGNATURE OF TAXPAYER
DATE
Is charter still active?
Yes
No
LLC
SIGNATURE OF TAXPAYER
DATE
Other: ________________________
Print pages 4 and 5. Send page 4 with your offer. Keep page 5 for your records.
ADOR 20-0001f (11/09)
Send this copy to Arizona Department of Revenue.
Print Offer
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Parent category: Financial