Fillable Form Oic-1 - Offer In Compromise (Page 4 of 4) in pdf

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Section 8 -

(continued)

I authorize the Georgia

l) By authorizing the GADOR to contact third parties including credit bureaus, I understand that I will not be

Department of Revenue to contact

notified of which third parties the GADOR contacts as part of the offer application process.

relevant third parties in order to

process my offer

I am submitting an offer as an

m) I understand if the liability sought to be compromised is the joint and individual liability of myself and my co-

individual for a joint liability

obligor(s) and I am submitting this offer to compromise my individual liability only, then if this offer is accepted,

it does not release or discharge my co-obligor(s) from liability. The GADOR still reserves all rights of collection

against the co-obligor(s).

I authorize the Georgia Department

(n) If Payment Option 2 is selected under Section 5 of this application, I authorize the Georgia Department of

of Revenue to withdraw money from

Revenue and its designated financial agent to initiate a monthly ACH electronic funds withdrawal entry to the

my bank account if I choose a

financial institution account indicated in Section 5 for payments of my state taxes included in this offer and the

monthly payment option.

financial institution to debit the entry to this account. I also authorize the financial institutions involved in the

processing of electric payments of state taxes to receive confidential tax information necessary to answer inquiries

and resolve issues related to those payments. This authorization is to remain in full force and effect until I notify

the Department to terminate the authorization. Offers paid using Payment Option 2 involving sales tax or

withholding tax will continue to accrue at the statutory interest rate.

Section 9

Mandatory Signatures

Under penalties of perjury, I declare that I have examined this offer, including accompanying schedules and statements, and to

the best of my knowledge and belief, it is true, correct and complete. I understand that to willfully prepare or present a

document that is fraudulent or false is a criminal misdemeanor under O.C.G.A. § 48-1-6.

Signature of Taxpayer

Date (mmddyyyy)

Signature of Spouse Taxpayer (if applicable)

Date (mmddyyyy)

Section 10

Application Prepared by Someone Other than the Taxpayer

If this application was prepared by someone other than the taxpayer, please fill in that person’s name and address below.

Name of Preparer

Signature of Preparer

Date (mmddyyyy)

Address (Street, City, State, and ZIP code)

Section 11

Third Party Designee

Do you want to allow another person to discuss this offer with the Georgia Department of Revenue?

Yes (if yes, complete information below)

Note: You must submit Form RD-1061 Power of Attorney if you want to authorize someone else to make decisions and act on your behalf regarding this

offer.

Designee’s Name

Telephone Number

Mail this application and all attachments to the following address:

Georgia Department of Revenue

Offer in Compromise Program

1800 Century Blvd., NE, Suite 9100

Atlanta, Georgia 30345-3209

OIC-1 (rev. July 2016)

Page 4

Form Oic-1 - Offer In Compromise Page 4

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