Form R-20211 - Document Checklist For Offer To Compromise Based On Serious Doubt As To Collectibility Page 2

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R-20211 (11/98)
State of Louisiana
Department of Revenue
Offer in Compromise
Based on Serious Doubt as to Collectibility
To: Secretary of Revenue
Name of taxpayer (business)
Date
Address
Account number(s)
Amount of offer
City, State, ZIP
Amount of liability
1. This offer is submitted by the person(s) listed below in an attempt to settle a tax liability resulting from
alleged violations of law or failure to pay a tax liability.
Name
Social Security Number
Street Address
City, State, ZIP
Name
Social Security Number
Street Address
City, State, ZIP
2. It is agreed that the Department of Revenue shall keep all amounts to which the taxpayer(s) may be
entitled, under the laws of the State of Louisiana, due to overpayment of any tax or other liability, includ-
ing interest and penalties, for periods ending before this offer is accepted, and the overpayment is not in
excess of the difference between the liability sought to be settled and the amount offered. Any such
refunds received after this offer is accepted must be returned immediately by the taxpayer.
3. It is also agreed that on notice to the taxpayer of the acceptance of this offer, the taxpayer shall have no
right to contest, in court or otherwise, the liability sought to be settled. If there is an installment payment
offer and there is a default in payment due under its terms, the Secretary of Revenue or a designee may
disregard the amount of the offer and, without further notice of any kind, assess and collect by levy the
balance of the original liability.
4. It is further agreed that the taxpayer(s) waives prescription applicable to the assessment and collection
of the liability sought to be settled and agrees to the suspension of prescription on assessment and
collection for the period during which the offer is pending. If settlement provides for installment pay-
ments, the suspension of prescription will be for an additional period ending one year after the due date
of the last payment. The offer shall be deemed pending from the date of acceptance of the waiver of the
statutory period of limitations until the date the offer is formally accepted, rejected, or withdrawn in
writing.
Please complete the reverse side of this form.

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