Form A-212 Petition For Compromise Of Taxes Based On Inability To Pay
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Click mouse on line below and enter name of petitioner. Tab throughout rest of form.
PETITION FOR COMPROMISE OF TAXES BASED ON INABILITY TO PAY
This form should only be used to petition the Wisconsin Department of Revenue for the compromise of taxes based on an in-
ability to pay in full in accordance with secs. 71.92(3), 73.13 and 77.62(5) Wis. Stats. The completed form and all supporting
documentation should be submitted to the office listed on your Statement of Account. Corporations must also complete and
submit Form A-213 Corporation Schedule A with this petition. NOTE: If your offer is accepted, you must pay that amount within
ten (10) days from the date the offer is accepted or pay in accordance with an approved payment schedule.
1. Name of Petitioner
Social Security Number
Seller's Permit Number
Withholding Number
Business Telephone
Business Address
( )
Home Address
Home Telephone
( )
2. Record of Taxes Due
Type of Tax
Taxable Period
Unpaid Liability
3. Failure to pay the taxes listed above is due to the following causes:
4. Source of funds for offer (list):
5. If the outstanding taxes were incurred in the operation of a business, has the business been discontinued?
Yes
No
If discontinued, when?
What disposition was made of the assets?
6. Family Information
Name of spouse
Petitioner, Date of Birth
Spouse, Date of Birth
Name(s) of dependent(s) - list
Relationship
Date of Birth
7. Employment Information
Petitioner
Spouse
Present employer
Gross salary per week
Take home pay per week
If unemployed, give date last employed and
Type date, then tab to
Type date, then tab to
gross salary per week
enter salary in same box.
enter salary in same box.
8. List names of banks and other financial institutions you have done business with any time during the past 3 years.
Name and Address
Name and Address
Do you rent a safety deposit box in your name or in any other name?
Yes
No
If yes, give name and address of bank where the box is
located.
A-212 (R.7-09)
Wisconsin Department of Revenue
To Page 2
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