Form Oic-1 - Offer In Compromise Application - 2005
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4OIC-1 (Rev 07/05)
Page 1
Georgia Department of Revenue
Offer in Compromise Application
(Please read instructions before completing this form)
1
.
Applicant(s) Name and Street Address
SS #
SS #
STI #
County
Daytime Phone # (
)
3. Applicant(s) Legal Structure
2. Applicant(s) Mailing Address (If different from above)
[
]
Individual
[
] Proprietorship
[
] Partnership
[
] Corporation
[
] Trust / Estate [
] Corp. Officer(s)
4.
I / We offer to pay the amount of $_______________ to compromise and settle the tax liabilities listed in Section 6 below and
will pay this amount in the following manner:
[
] Paid In Full with this offer. (Make check payable to the “Georgia Department of Revenue”)
(Check One Only)
[
] A deposit of $ __________ is attached, the balance to be paid within 30 days from acceptance.
[
] No Deposit is attached. Full payment will be made within 30 days from acceptance.
NOTICE:
Any payment received with this offer is nonrefundable and will be credited to the tax liability regardless of the
disposition of the offer. The acceptance of any payment constitutes neither a waiver of any of the Department’s rights, nor an
acceptance of the offer.
5.
Check One:
[
] $100 Application Fee Attached
or
[
] Form OIC-11 Application Fee Waiver Attached
NOTICE:
The application fee is required with each OIC-1 application and is nonrefundable. The fee is not part of the offer and
will be credited to the tax debt only if the offer is accepted. The application fee will not be credited to the tax debt if the offer is
declined. Please see instructions regarding waiver of the Application Fee based on financial hardship.
)
6.
Description of Tax Liabilities to Be Compromised (Check and complete all that apply
Tax Type
Account Number
Period(s)
[
] Individual Income Tax
[
] Employer Withholding Tax
[
] Sales & Use Tax
[
] Corporate Income Tax
[
] Other (Specify)
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