Form 656 - Offer In Compromise Page 4

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Item 9 — Explanation of Circumstances
I am requesting an offer in compromise for the reason(s) listed below:
Note: If you are requesting compromise based on doubt as to liability, explain why you don’t believe you owe the tax.
If you believe you have special circumstances affecting your ability to fully pay the amount due, explain your situation.
You may attach additional sheets if necessary.
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Item 10
If I/we submit this offer on a substitute form, I/we affirm that this
form is a verbatim duplicate of the official Form 656, and I/we agree
to be bound by all the terms and conditions set forth in the official
Form 656.
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.
OFFICIAL USE ONLY
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10(a) Signature of Taxpayer — proponent
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Date
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10(b) Signature of Taxpayer — proponent
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Date
For Official Use Only
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Signature of Authorized Internal Revenue Service Official
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Title
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Date
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