Form Ct-656a - Offer Of Compromise
ADVERTISEMENT
1
2Department of Revenue Services
Form CT-656a
State of Connecticut
25 Sigourney Street
Offer of Compromise
Hartford CT 06106
Rev. 09/04
Name, DBA, and Address of Taxpayer(s)
Date of Birth
Number of dependents
claimed on federal
income tax return
Connecticut Tax Registration Number
Social Security Number or
For DRS Use Only
Federal Employer Identification Number
Amount Paid
Date Received
To: Commissioner of Revenue Services
Date:
$
I understand this offer is based on doubt as to collectibility and will be accepted only after that fact has been
established. A completed financial statement must be included with this offer.
I submit this offer to compromise the tax liabilities plus interest, penalties, additions to tax, and additional amounts
required by law (tax liability) for the tax type and period(s) listed below.
Tax type
Period(s)
Is this bill under appeal?
I offer to pay $ _______________________ by ____________________ .
DRS must receive payment within 30 days from the date the offer is accepted. Interest continues to accrue on
any unpaid balance until the date it is paid in full.
Important: Read All Requirements, Terms, and Conditions
Declaration: I declare under penalty of law that I have examined this application and to the best of my knowledge
and belief, it is true, complete, and correct. I understand the penalty for willfully delivering a false application to
DRS is a fine of not more than $5,000, or imprisonment for not more than five years, or both.
Print Name
Signature
Date
Spouse’s Name (if joint liability)
Spouse’s Signature (if joint liability)
Date
Signature of Authorized DRS Official
Title
Date
Disposition:
Conditional Acceptance
Rejection
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial