Form 656-A - Income Certification For Offer In Compromise Application Fee And Payment Page 2
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1
2Department of the Treasury — Internal Revenue Service
Income Certification for Offer in Compromise
656-A
Form
Application Fee and Payment
(March 2009)
(For Individual Taxpayers Only)
If you are not required to submit the fee or payments based on your income level, you must complete this form
and attach it to the front of your Form 656. You do not need to attach the Offer in Compromise Application Fee
and Payment Worksheet to the Form 656.
1. Your Name
2. Social Security Number (SSN) or
(Last, First, Middle initial) (Please Print)
Taxpayer Identification Number (TIN)
3. Spouse's Name
(Last, First, Middle initial) (Please Print)
4. Social Security Number (SSN) or
Taxpayer Identification Number (TIN)
5. Family Unit Size
(This number is transferred over from your Offer in Compromise Application Fee and Payment Worksheet)
6. Total Household Monthly Income
(This amount is transferred over from your Offer in Compromise Application Fee and Payment Worksheet)
$
Certification: Under the penalty of perjury, I certify that I am not required to submit an Offer in Compromise
application fee or payment, based on family unit size and income.
Your Signature
Date
Spouse's Signature
(if submitting a joint Offer in Compromise)
Date
656-A
Catalog Number 28300X
Form
(Rev. 3-2009)
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