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. Please include your name and SSN or EIN on all additional sheets or
supporting documentation.
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Item 10 — Source of Funds
/
I
We shall obtain the funds to make this offer from the following source(s):
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Item 11 — Mandatory Signature(s)
For Official Use Only
/
/
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
I accept the waiver of the statutory period of limitations on assessment
agree to be bound by all the terms and conditions set forth in the
for the Internal Revenue Service, as described in Item 8(e).
official Form 656.
_________________________________________________
Under penalties of perjury, I declare that I have examined this
Signature of Authorized Internal Revenue Service Official
offer, including accompanying schedules and statements, and
to the best of my knowledge and belief, it is true, correct and
_________________________________________________
complete.
Title
_____________________________________________________
_________________________________________________
11(a) Signature of Taxpayer
Date
_____________________________________________________
Date
_____________________________________________________
11(b) Signature of Taxpayer
_____________________________________________________
Date
Item 12 — If this application was prepared by someone other than the tapayer, please fill in that person’s name and address below.
Name:
Address:
(if known)
Item 13
Preparer’s
Date
Check if
Preparer’s CAF no. or PTIN
signature
self-employed
Paid
Preparer’s
Firm’s name (or
EIN
yours if self-employed),
Use Only
address, and ZIP code
Phone no. (
)
Item 14
Do you want to allow another person to discuss this offer with the IRS?
Yes. Complete the following.
No
Third Party
Designee’s
Phone
Designee
(
)
name
no.
24

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