Fillable Form Oic-1 - Offer In Compromise (Page 2 of 4) in pdf

Form Oic-1 - Offer In Compromise Page 2

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SECTION 4

Application Fee

Did you include a $100 application fee with application?

Yes

If no, you must include a properly completed Form OIC-1A Income Certification for Offer in Compromise Application Fee.

SECTION 5

Offer to Pay

I/We offer to pay $____________________ (must be more than zero).

Complete Section 6 of this application to explain where you will

obtain the funds to make this offer.

Check one of the following:

Lump sum cash offer: The offer must be paid within 60 days from written acceptance to the offer.

Short-Term Deferred Payment Offer: Offer amount must be paid within 60 months from written notice of acceptance of the offer and must

be paid in regular, monthly amounts. First payment will be automatically debited from your financial institution on the 10

day of the month

following written acceptance of the offer. Interest will continue to accrue for all sales tax and withholding tax liabilities. Complete the

following:

$__________ will be automatically deducted from my financial institution for _________ months.

Financial Institution Name:_____________________________________________________________________________________

Mailing Address (street, city, state, zip):__________________________________________________________________________

Names on the Account: _______________________________________________________________________________________

Routing Number:

Checking Account

Savings Account

Account Number:

SECTION 6

Source of Funds

I/We shall obtain the funds to make this offer from the following source(s):

SECTION 7

Explanation of Circumstances

I/we request an Offer in Compromise for the reason(s) listed below:

NOTE: Explain your situation if you believe the tax is incorrect or if you have special circumstances affecting your ability to fully pay the amount due. You

may attach additional sheets if necessary. You should also attach documentation to support your claim that the tax is incorrect.

OIC-1

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