Offer In Compromise Application Form
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1
2OFFER IN COMPROMISE APPLICATION
For Department Use Only
NAME:
Department # 400-5933-9
DBA:
ADDRESS:
CC
M/O
Effective Date
Social Security Number
EDD Account Number
Amount Paid
Log #
$
1. The undersigned submits this Offer in Compromise for payment of California State payroll tax liability, which includes
Unemployment Insurance, State Disability Insurance, Employment Training Tax, Personal Income Tax, penalty and
accrued interest described as follows:
2. The total amount of the offer $
. See specific instructions.
3. A full financial disclosure, including community property, is contained in the financial statement, submitted as part
of this application.
4. Explain the facts and reasons why this offer should be accepted:
5. All payments made with this offer are submitted voluntarily. In the event an offer is not accepted, the amount will either
be applied to the liability or refunded, at the discretion of the individual submitting the offer. Check the appropriate box
below:
.
Retain the amount offered/apply to account
.
Refund the amount paid
Monies paid to the Department with an offer will not be applied against the liability until the offer has been accepted.
DE 999A Rev. 1 (6-07) (INTERNET)
Page 1 of 4
CU
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