Form Oic-1 - Offer In Compromise Application - 2001 Page 4

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OIC-1 (Rev 12/01)
Page 4
13.
DISCLOSURE AGREEMENT
This section is to be completed only if an Offer in Compromise is currently pending or has been recently acted
upon by the IRS for the applicant. Separate signature(s) are required for this section.
[
] Completed
(Date
)
[ ] Accepted (Amount $ __________) or [
] Declined
[
] Pending
(Date filed
)
IRS Agent Assigned
[
] To be filed
(Date
)
Phone Number
Tax Period(s) Covered
Amount Owed
Federal Taxpayer Identification No.
$
By my/our signature(s) below, I/we authorize the Georgia Department of Revenue and the Internal Revenue Service
to exchange information from their respective files regarding my/our pending or completed Offer in Compromise.
APPLICANT’S SIGNATURE
DATE
APPLICANT’S SIGNATURE
DATE
ATTORNEY’S OR ACCOUNTANT’S SIGNATURE
DATE
:
For information or assistance, contact one of the following DOR Regional Offices
ALBANY
P.O. Box 943
Rome, GA 30162-6004
P.O. Box 1357
Douglas, GA 31534-0943
(706) 295-6061
Albany, GA 31702-1357
(912) 389-4094
FAX: (706) 295-6744
(229) 430-4241
FAX: (912) 389-4411
FAX: (229) 430-3922
SAVANNAH
LITHIA SPRINGS
P.O. Box 13547
ATHENS
P.O. Box 1079
Savannah, GA 31416-0547
P.O. Box 1843
Lithia Springs, GA 30122-7079
(912) 356-2140
Athens, GA 30603-1843
(770) 732-5812
FAX: (912) 353-3012
(706) 542-6058
FAX: (770) 732-5823
FAX: (706) 542-9973
TUCKER
MACON
2082 E. Exchange Place
AUGUSTA
P.O. Box 4368
Suite 120
P.O. Box 211708
Macon, GA 31208 –4368
Tucker, GA 30084-5334
Augusta, GA 30917-1708
(478) 751-6055
(770) 724-6500
(706) 737-1870
FAX: (478) 751-6016
FAX: (770) 414-3558
FAX: (706) 731-7956
ATLANTA
COLUMBUS
P.O. Box 16749
P.O. Box 1698
Atlanta, GA 30321
Columbus, GA 31902-1698
(404) 362-6422
(706) 649-7451
FAX: (404) 968-0472
FAX: (706) 649-1050
Mail this application and all attachments to the following address:
Georgia Department of Revenue
Offer in Compromise Program
1800 Century Center Blvd., NE, Suite 15110
Atlanta, Georgia 30345-3205
ROME
Attention: Program Administrator
DOUGLAS
P.O. Box 6004

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