Form Oic-1 - Offer In Compromise Page 4
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initiate a monthly ACH electronic funds withdrawal entry to the
(r) If the taxpayer does not fully satisfy the terms of offer or
financial institution account indicated in Section 4 for
any modification thereto, the Department will recoup the
payments of my state taxes included in this offer and the
$1,922 cost of processing the offer from the taxpayer.
financial institution to debit the entry to this account. I also
(s) A $100 cost assessment shall be charged to any
authorize the financial institutions involved in the processing
subsequent modifications to the offer.
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. Note: Short Term Deferred Payment
Offers involving sales tax or withholding tax will continue
to accrue at the statutory 12% 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
Daytime Telephone Number
Date (mmddyyyy)
Signature of Taxpayer
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?
No
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 17205
Atlanta, Georgia 30345-3209
OIC-1
Page 4
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