Form R-20211 - Document Checklist For Offer To Compromise Based On Serious Doubt As To Collectibility Page 3
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4R-20211 (11/98)
5. The following facts and reasons are submitted as justification for acceptance of this offer. Statement of
Financial Condition and Other Information (R-20212) also must be filed.
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6. It is understood that this offer will be considered and acted upon in due course and that it does not
relieve the taxpayer(s) from the liability sought to be settled unless and until the offer is accepted in
writing by the Secretary, two assistant secretaries, and the Louisiana Board of Tax Appeals, and there
has been full compliance with the terms of the offer.
I accept the waiver of prescription for the tax
Under penalties of perjury, I declare that I have ex-
period(s) of:
amined this offer, including accompanying docu-
ments, and to the best of my knowledge and belief,
it is true, correct, and complete.
Signature of authorized officer
Signature of taxpayer
Title
Date
Signature of taxpayer
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