Form Oic-1 - Offer In Compromise Application - 2001
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4OIC-1 (Rev 12/01)
Page 1
Georgia Department of Revenue
Offer in Compromise Application
1.
Applicant(s) Name and Street Address
SS #
SS #
FEI #
County
Daytime Phone # (
)
2. Applicant(s) Mailing Address
3. Applicant(s) Legal Structure
(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: (Check One Only)
[
] Paid In Full with this offer. (Make check payable to the “Georgia Department of Revenue”)
[
] A deposit of $ __________ is attached, the balance to be paid within ___ 30 ___ 60 ___ 90 days from acceptance.
[
] No Deposit is attached. Full payment will be made within ___ 30 ___ 60 ___ 90 days from acceptance.
5.
The Georgia Department of Revenue will immediately deposit any payment made with this offer, to be held pending a final
decision or the applicant’s withdrawal of the offer. The deposit of this payment constitutes neither a waiver of any of the
Department’s rights, nor an acceptance of the offer. If the Department rejects the offer or it is withdrawn, I/we request that
the amount tendered be:
[
] APPLIED TO MY/OUR TAX LIABILITY
OR
[
] RETURNED TO ME/US
Description of Tax Liabilities To Be Compromised
6.
Tax Type
Account Number
Period(s)
[
] Individual Income Tax
[
] Employer Withholding Tax
[
] Sales & Use Tax
[
] Corporate Income Tax
[
] Other (Specify)
7.
Reason for Offer
[
] DOUBT AS TO COLLECTABILITY
AND / OR
[
] DOUBT AS TO LIABILITY
(“I am unable to pay this tax”)
(“I do not believe I owe this tax”)
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