Fillable Form 656 - Offer In Compromise - Department Of The Treasury (Page 4 of 4) in pdf

Page 4 of 4

Section VIII

Mandatory Signatures

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 agree to be bound by all the terms and conditions set forth in the official Form 656.

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.

Signature of Taxpayer

Date

Taxpayer

Attestation

Signature of Taxpayer

Date

Official Use Only

I accept the waiver of the statutory period of limitations on assessment for the Internal Revenue Service, as described in Section V(e).

Signature of Authorized Internal Revenue Service Official

Date

Title

Section IX

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

Address

(if known) (Street, City, State, ZIP code)

Paid Preparer Use Only

Section X

Name of Preparer

Signature of Preparer

Date

Check if

Preparer's CAF no. or PTIN

self-employed

Firm's name (or yours if self-employed), address, and ZIP code

EIN

Telephone number

(

)

Third Party Designee

Section XI

Do you want to allow another person to discuss this offer with the IRS?

Yes. Complete the information below.

Designee's name

Telephone number

(

)

Privacy Act Statement

We ask for the information on this form to carry out the internal revenue laws of the United States. Our authority to request this information is Section 7801 of the Internal

Revenue Code.

Our purpose for requesting the information is to determine if it is in the best interests of the IRS to accept an Offer in Compromise. You are not required to make an Offer in

Compromise; however, if you choose to do so, you must provide all of the taxpayer information requested. Failure to provide all of the information may prevent us from

processing your request.

If you are a paid preparer and you prepared the Form 656 for the taxpayer submitting an offer, we request that you complete and sign Section X on Form 656, and provide

identifying information. Providing this information is voluntary. This information will be used to administer and enforce the internal revenue laws of the United States and may

be used to regulate practice before the Internal Revenue Service for those persons subject to Treasury Department Circular No. 230, Regulations Governing the Practice of

Attorneys, Certified Public Accountants, Enrolled Agents, Enrolled Actuaries, and Appraisers before the Internal Revenue Service. Information on this form may be disclosed

to the Department of Justice for civil and criminal litigation.

We may also disclose this information to cities, states and the District of Columbia for use in administering their tax laws and to combat terrorism. Providing false or

fraudulent information on this form may subject you to criminal prosecution and penalties.

656

Catalog Number 16728N

Form

(Rev. 2-2007)